TOBACCO CONTROL ADVOCACY AND POLICIES IN DEVELOPING COUNTRIES

There were approximately 1.1 billion smokers in the world in 2000, a figure predicted to exceed 1.6 billion by the year 2025. Smoking causes one in ten deaths globally, and by 2030 it will be closer to one in six. By 2020, it is predicted that 70 percent of people who die from smoking-related causes will live in developing countries. In addition, the age at which people first try smoking in developing countries is decreasing. Between 82,000 and 99,000 young people start smoking every day, over 80 percent of whom live in developing countries. While many developing countries have low rates of smoking among females, these rates are also on the rise. Aggressive marketing by the tobacco industry has fueled this trend.

During the last two decades of the twentieth century, governments responded to the smoking epidemic with diverse tobacco control (TC) policies. These measures have faced many domestic and global challenges, including a lack of funds and competition with other pressing problems. Serious challenges to TC policies also come from transnational tobacco companies (TTCs).

ELEMENTS OF TOBACCO CONTROL POLICIES

Tobacco control policies may address both the supply and demand side of the tobacco equation. Supply-side controls include limiting tobacco sales and imports, as well as policies to support alternative crops or livelihoods. Demand-side controls include taxation, bans (partial or total) on advertising and other forms of tobacco marketing, restrictions on where people smoke, prohibiting tobacco sale to minors, health warnings, restrictions on the ingredients in tobacco products, and the provision of accessible nicotine replacement therapies. Policies vary considerably across nations.

Many demand-side measures aim to reduce smoking prevalence and discourage young people from starting. Taxation has been shown to be an effective tool. Between 1979 and 1991, there was an inverse relationship between the real tobacco price index and teen smoking in Canada. In South Africa, cigarette taxes are now 47 percent of the price of a package. Such policies, however, face severe opposition from the tobacco industry. Mexico, for example, reduced taxes on cigarettes in the late 1980s under pressure from tobacco companies.

Banning tobacco advertising is another policy tool. China has laws that ban tobacco advertising in the print media and on radio and television, as well as advertising directed at adolescents—though these laws are unevenly enforced. South Africa also bans direct advertising of cigarettes on television, and recently banned tobacco sponsorships for sporting and cultural events. Other countries lag behind. In Senegal, advertising through sponsorships of sporting and cultural events is common. Under Mexico's partial ban, companies are discouraged from associating smoking with civic, religious, or sports activities, and are not allowed to use models younger than twenty-five years old. Tobacco advertising is permitted on television in the evening, however.

Policies to control environmental tobacco smoke (ETS) are also becoming more common in developing countries. Doctors, nurses, and teachers smoke in the workplace in Senegal, and in Mexico few restrictions exist on smoking in public places other than in poorly ventilated public buildings. In South Africa, however, smoking is restricted in government buildings, airports, and restaurants. Enforcement of clean air policies and associated penalties is often minimal. In China, smoking is restricted in most public places, on public transportation, and on domestic airline flights—but the fine for infractions is less than the cost of a package of imported cigarettes.

Warning labels on cigarette packages tend to be worded much less strongly in developing countries. Statements such as "This product may be harmful to your health" or "Smoking is hazardous to your health" are used. This is in stark contrast to Canada's use of graphic images of the impact of smoking on health, introduced in January 2001.

Despite successes, country-specific, comprehensive TC policies are still uncommon and their ineffective implementation is alarming. In countries such as Senegal and China, TC policies of the 1980s and 1990s have become progressively weaker due to poor enforcement.

CHALLENGES, AND A ROLE FOR CIVIL SOCIETY

Limited funding and large disparities in the will-ingness of the public and policy makers to develop and enforce policies pose a challenge to the success of TC policies. Barriers also include low literacy rates, multiple languages within a country, and high rates of smoking among health professionals—especially doctors, who exert a significant influence over communities' attitudes and behaviors. The heavy dependence of some economies on tobacco is also a threat. In Malawi and Zimbabwe, governments fear that a decrease in tobacco consumption would eventually lead to higher unemployment and lower foreign capital. Many challenges are easier to overcome where strong political support, popular support, and relevant research findings exist, as South Africa has proven. Effective advocacy organizations also contribute to the development of TC policies.

Advocacy groups are sometimes invited to participate in the development of TC policies. Unfortunately, civil society in developing countries may be weak or focused on other pressing issues, such as democracy, the environment, or primary health care. Nevertheless, organizations such as ASH Thailand (Action on Smoking and Health) have played an active role in the development and implementation of TC policies and serves as models for others. Unfortunately, tobacco companies encourage groups to lobby governments against new TC policies, for lenient legislation, or for free trade in tobacco.

For instance, in the 1980s, American-based TTCs began to pressure Asian countries to open their markets through a group called the United States Cigarette Exporting Association (USCEA). In 1985, despite a tobacco import ban, USCEA began advertising in Thailand. The following year, the Thai Anti-Smoking Campaign Project started to pressure the government until, in 1989, all tobacco advertising was banned. When negotiations between USCEA and the Thai government broke down later that year, the association asked the U.S. trade representative to use the U.S. Trade Act to pressure the Thai government to open the cigarette market, prompting a strong reaction from Thai and international anti-smoking groups and advocates. Finally, in 1990, the General Agreement on Trade and Tariffs (GATT, the forerunner of the WTO) ruled that Thailand could not continue to ban imports of cigarettes, but that it could continue to enforce its ban on tobacco advertising provided the law was applied equally to domestic and foreign products. Thailand's partial success in fighting American-based tobacco companies is indicative of the difficulties in fighting TTCs' destructive use of its power.

TOBACCO CONTROL POLICIES IN A GLOBAL CONTEXT

Globalization comprises two general trends. The first is economic globalization by way of global trade liberalization. The second trend is toward a transnational sharing of cultural, political, and social values, which has been factored by electronic communications and the media. Both trends present distinct challenges and opportunities to effective TC policies.

Economic globalization reduces trade barriers between countries, including tariffs, subsidies, and import restrictions. Tobacco control researchers, advocates, and health officials are concerned that these agreements open the door to TTCs to flood the markets of developing countries with their cigarettes, and thus hinder a nation's ability to control tobacco use. Using homogenizing cultural images, TTCs also exploit social and cultural globalization in their marketing (e.g., Philip Morris's Marlboro man and ads focused on women suggesting that smoking is modern and emancipated).

Given political commitment and organized efforts, it is possible to successfully fight the efforts of the tobacco companies. The effectiveness of cross-national coalitions of advocacy and research groups will continue to be crucial (e.g., the International Non-Governmental Coalition Against Tobacco, GLOBALink), as will the efforts of organizations such as the United Nations.

INTERNATIONAL ORGANIZATIONS AND TOBACCO CONTROL POLICIES

The World Bank no longer lends money to countries for tobacco-related projects and has recently laid out its approach to tobacco control, which focuses on demand-side strategies including taxation, non-price measures, and cessation therapies. In 1998, the WHO created the Tobacco Free Initiative (TFI), which aims to reduce smoking prevalence and tobacco consumption globally. TFI is also developing the Framework Convention for Tobacco Control (FCTC), which, if signed by all WHO member countries, will provide a legal instrument as the basis of global and national TC policies in the face of transnational threats. Scheduled to be completed by May 2003, the FCTC will enable effective regional and global cooperation regarding TC concerns such as smuggling and advertising.

The health, economic productivity, and quality of life of the citizens in developing countries is under threat by increased tobacco consumption. Yet, despite many efforts, research, policy, and enforcement remain inadequate. Future success will largely depend on a strong research base to support policy development, as well as effective advocacy and coalition building to bridge the gap between research and policy.

Linda Waverley Brigden

Montasser Kamal

(see also: Counter-Marketing of Tobacco; Environmental Tobacco Smoke; International Development of Public Health; Smoking Behavior; Smoking Cessation; Smuggling Tobacco; Taxation of Tobacco; Tobacco Control )

Bibliography

Aftab, M.; Kolben, D.; and Lurie, P. (1999). "International Cigarette Labeling Practices." Tobacco Control 8(4):368–372.

Cunningham, R. (1996). Smoke and Mirrors: The Canadian Tobacco War. Ottawa: IDRC Books.

Ernster, V.; Kaufman, N.; Nichter, M.; Samet J.; and Yoon, S. (2000). "Women and Tobacco: Moving from Policy to Action." Bulletin of the World Health Organization 78(7):891–901.

Global Analysis Project Team (2000). "Political Economy of Tobacco Control in Low-Income and Middle-Income Countries: Lessons from Thailand and Zimbabwe." Bulletin of the World Health Organization 78(7):913–919.

Hammond, R. (1998). Addicted to Profit: Big Tobacco's Expanding Global Reach. Washington, DC: Essential Action.

Health Canada (2000). "New Tobacco Regulations Become Law." News Release, June 28, 2000.

Joossens, L. (2000). "From Public Health to International Law: Possible Protocols for Inclusion in the Framework Convention on Tobacco Control." Bulletin of the World Health Organization 78(7):930–937.

Ong, E. K., and Glantz, S. A. (2000). "Tobacco Industry Efforts Subverting International Agency for Research on Cancer's Secondhand Smoke Study." The Lancet 355:1253–1259.

Saloojee, Y., and Dagli, E. (2000). "Tobacco Industry Tactics for Resisting Public Policy on Health." Bulletin of the World Health Organization 78(7):902–910.

Taylor, A., and Bettcher, D. (2000). "WHO Framework Convention on Tobacco Control: A Global 'Good' for Public Health." Bulletin of the World Health Organization 78(7):920–929.

Townsend, J. (1998). "The Role of Taxation Policy in Tobacco Control." In The Economic of Tobacco Control: Towards an Optimal Policy Mix, eds. I. Aberdian, R. van der Merwe, N. Wilkins, and P. Jha. Cape Town: Applied Fiscal Research Centre, University of Cape Town.

Vateesatokit, B.; Hughes, B.; and Ritthphakdee, B. (2000). "Thailand: Winning Battles, But the War's Far from Over." Tobacco Control 9:122–127.

World Bank (1999). Curbing the Epidemic: Governments and the Economics of Tobacco Control. Washington, DC: The World Bank.

Yach, D., and Bettcher, D. (2000). "Globalization of Tobacco Industry Influence and New Global Responses." Tobacco Control 9:206–216.