Kill the killer

Mumbai: The World Health Organisation (WHO) estimates that at present 4.2 million deaths per year are caused by tobacco. The annual death toll attributable to tobacco is expected to rise to 8.4 million in 2020, with tobacco contributing to one in eight deaths.

An international negotiating body (INB), involving governmental delegations from WHO member states, is currently negotiating a framework convention for tobacco control (FCTC). This treaty aims to provide a framework for national action and mechanisms for international cooperation, both intended to "continually and substantially reduce the prevalence of tobacco use and exposure to tobacco smoke" and "to protect present and future generations from the devastating health, social, environmental consequences of tobacco consumption."

Traditionally, strategists for tobacco control have advocated 'demand reduction' as the sole or principal mode of reducing tobacco consumption in the world. This is based on the understanding that measures such as increased taxes and prices, stricter and more prominent health warnings, bans on tobacco product promotion, curbs on smoking in public places and educating the community on tobacco-related risks would lead to a reduction in the use of tobacco. These measures are expected to reduce the demand for tobacco over time and the market is expected to respond with a downscaling of production and supply.

The debates during the negotiations of the INB, as well as the recent report of the Economic and Social Council (ECOSOC) of the United Nations, have brought to fore the need for measures to reduce global tobacco production, alongside measures to reduce global tobacco consumption. During the meetings of the INB, several developing countries proposed that a global fund should be established to, inter alia, shift the agricultural production of tobacco and the manufacture of tobacco products to alternate occupations.

This elicited a sharp response from the World Bank as well as a section of non-governmental organisations from the developed countries who are observers at the INB. Their main arguments, against aiding such economic transition, are:

1. 'Demand reduction' is the only effective strategy for tobacco control.
   
2. The demand for tobacco will continue to be high or decline very slowly, over the next 50 years — therefore, there will be no dislocation of tobacco farmers or workers requiring early rehabilitation.
   
3. Even if some countries reduce their production, others will compensate by increasing production, so long as there is a continuing demand.
   
4. The talk of any adverse impact on tobacco farmers or workers will only strengthen the attempts of the tobacco industry to frighten the policymakers and workforce of tobacco growing countries. These arguments need close scrutiny.

First, it is illogical to affirm that demand reduction strategies alone will succeed and at the same time aver that demand will not really decline in any meaningful way over the next 50 years. The need for multiple demand reduction measures is indisputable. The developing countries have, in fact, steadfastly advocated strong measures for tobacco control.

Whether it is the matter of stating unequivocally that public health has precedence over trade or a call for a complete ban on all forms of advertising, the position of most developing countries has been stronger than that of some developed countries. The issue, however, is whether the demand reduction measures alone will succeed in ensuring early and effective control of tobacco at the global level.

ECOSOC, at its recent meeting in July 2002, received the report of an ad hoc inter-agency task force on tobacco control, which consisted of 19 international organisations. The report makes for dismal reading on the prospects of global tobacco control. The 'best case scenario' projected by the report is based on a potential 1-per cent annual reduction in the prevalence of smoking, with the assumption that "all countries implement effective and comprehensive tobacco programmes and achieve results similar to those achieved by the US states of California, Massachusetts, Arizona and Oregon during the past decade."

Even at this level, the absolute global numbers of smokers are projected to rise from 1,282.5 million in 2000 to 1,385.1 million in 2020. The rise, in absolute numbers, is even more alarming for the developing countries — from 977.3 million in 2000 to 1,290.1 million in 2020 to 1,807.2 million in 2050 (see table). The situation will be far worse if current rates of smoking prevalence continue — the global count of smokers is expected to rise to 1,693.5 million by 2020 and 2,217.9 million by 2050.

These estimates are confined to smokers and do not take into account the non-smoking forms of tobacco whose use is widely prevalent in countries like India and is expected to rise over the years. The overall projected scenario is of a growing global demand for tobacco despite 'effective and comprehensive tobacco programmes.'

Surprisingly, these estimates are used to provide assurance to tobacco-growing countries that the fear of adverse effects on employment in tobacco-growing states is unfounded. A World Bank report entitled 'Curbing the Epidemic: Governments and the Economics of Tobacco Control' concluded that "fears of net job losses are unfounded." This is poor consolation for those who wish to see the tobacco trade dwindle and disappear in the next few decades.

The ECOSOC report also states that growing global income, expanding global population and trade liberalisation will lead to increased tobacco consumption, especially in developing countries. It cautions that a 1-per cent annual reduction in tobacco prevalence would constitute a formidable success and concludes that "regardless of how satisfying it would be to see the global tobacco market contract, several decades, at best, will be necessary to reach such formidable achievements."

The ECOSOC report also states that "production and consumption of tobacco are expected to continue to expand, but patterns for both demand and supply of tobacco are expected to differ quite markedly between developing and developed countries." Despite a 0.5-per cent annual decline in consumption in the developed countries, an annual growth rate of 3.2 per cent is projected for global tobacco consumption in this decade.

The report also predicts a shift in production from developed to developing countries and states that "the higher profitability of tobacco production in comparison with other cash crops in developing countries strengthens this tendency for tobacco production to shift to developing countries."

On the basis of such reports, the suggestion of providing financial and other market-support mechanisms, to aid farmers in developing countries to shift to alternate crops, has been dismissed as unwarranted, since business would be booming for many years to come and rehabilitation would not be required. What the critics of such a supply-side action must appreciate is that tobacco control requires this shift as a proactive strategy and not merely as a reactive response.

As global tobacco production increases and consumption falls in the developed countries, the production surplus will aggressively seek developing country markets. Markets that are traditionally open to developing countries have also been acquired by manufacturers from the developed countries over the past two decades. Therefore, even in tobacco-growing developing countries, the shrinkage in tobacco exports would result in a production surplus that would seek increased utilisation in the domestic market. This grim scenario demands action both to reduce tobacco production within the developing countries as well as to prohibit or severely restrict imports from other countries.

The argument that even if some countries reduce production, others would rush to fill the rising demand is valid only as long as we regard free trade in tobacco as sacrosanct. If public health is accorded higher priority over free trade, as it should be, developing countries which downscale their domestic tobacco production can also prevent the entry of tobacco or tobacco products from other countries through import restrictions which cannot be nullified by the World Trade Organisation.

Freeing public health action for tobacco control from the shackles of trade agreements is not only a moral imperative but can also draw upon recent precedents. When the outbreak of bovine spongiform encephalopathy (mad cow disease) led to a ban on British meat exports to Europe or the scare of anthrax in North America led to liberalisation of ciprofloxacin imports and compulsory production licensing, public health concerns clearly outweighed trade treaties. The escalating global epidemic of tobacco-related diseases, especially in the developing countries, is an even greater public health emergency and trade cannot be allowed to obstruct the introduction and implementation of import restrictions.

The apprehension that such financial support intended for crop diversification and labour redeployment may be misused, by countries which are not serious about downsizing tobacco production, may be addressed by linking clearly defined performance indicators to continued support and through effective monitoring systems.

It is not unthinkable, therefore, that tobacco growing countries should be encouraged or even mandated to progressively reduce tobacco production — perhaps 30 per cent by 2020 and 100 per cent by 2050. Developing countries, which grow tobacco, may be provided assistance to help farmers develop alternate crops, with initial market support. A part of the proposed global fund could be devoted for this, while the rest of it should be used to support all developing countries in carrying out the demand reduction measures envisaged in the FCTC.

The only supply reduction activity that some developed countries appear to be interested in, at present, is to curb smuggling — they do not even accept provisions in the FCTC for eliminating duty-free sales or prohibiting vending machines. While action to combat smuggling is very much required, that will merely lead to a better management of the expanding global tobacco trade and will not significantly reduce overall tobacco consumption.

If we are serious about tackling the threat of tobacco, steps to reduce the supply of tobacco must involve measures to reduce the production of tobacco. We cannot solely depend on market mechanisms to achieve that since the global demand for tobacco is projected to increase rather than decrease and the tobacco industry too will do its best to influence the market in many overt and covert ways.

The plea that a discussion on supply-side issues should be avoided as that will only strengthen the tobacco industry's attempts to rally farmers and workers against tobacco control is misplaced. Tobacco farmers and workers will continue to be manipulated and misutilised by the tobacco industry if no incentives are provided to them for seeking alternate occupations.

They are already being mobilised to oppose the FCTC in many developing countries. A credible plan for progressive assisted disengagement and diversification will win them over as willing partners in tobacco control and also comfort policymakers who are wary of antagonising this influential political constituency.

It should also be remembered that tobacco agriculture was not a choice originally made by the developing countries. Historically, tobacco was brought into those countries by those who colonised them. Vast tracts of land were, over time, diverted to the cultivation of this commercial crop, which was profitable for the economies of the colonial countries.

The task of now shifting to other forms of agriculture should not become a burden to be entirely borne by the developing countries. The international community must step in to assist that process, to correct a historical 'wrong' of the past and perform a historical 'right' that will be applauded by the future.

Present and projected estimates of the number of smokers by country category and year (2000, 2020, 2050) for alternate scenarios of reduced and constant prevalence rates

Source: ECOSOC Report (Ref. 4)