Can WHO Plan Curb Smoking?

Despite the well-known dangers of tobacco, more than a billion people worldwide still smoke cigarettes. On Thursday, in its first report on global tobacco use and control efforts, the World Health Organization helped shed light on why the number of smokers remains so high. Though tobacco is the world's leading preventable cause of death--killing an estimated 5.4 million people a year (more than tuberculosis, HIV/AIDS and malaria combined)--the WHO report found that, while 152 countries have pledged to implement recommended tobacco-control policies, only a handful have taken strong action already. Governments around the world still take in, on average, more than 500 times as much from tobacco taxes as they spend on tobacco control.

WHO--along with the Campaign for Tobacco-Free Kids, the U.S. Centers for Disease Control, the World Lung Foundation and Johns Hopkins University--is hoping to change that by promoting a new program it calls MPOWER, a package of six tobacco-control policies it is urging all governments to adopt. NEWSWEEK's Karen Springen discussed the plan with Jonathan Samet, chair of the department of epidemiology and director of the Institute for Global Tobacco Control at Johns Hopkins Bloomberg School of Public Health, and Heather Wipfli, project director of the Institute for Global Tobacco Control. Excerpts: 

NEWSWEEK: What should governments' role be in combating this public-health problem?
Heather Wipfli:
First, monitor the epidemic within the country, know how many smoke. Second, protect people from exposure to second-hand smoke. Less than 5 percent of the world's population are protected by smoke-free regulations. The third action is to offer smoking cessation and treatment to those who are already addicted. The fourth point is that we need to warn world populations, including public service announcements and hard-hitting and large warning labels on all packaging for tobacco products. The fifth is to enforce bans on the advertising and promotion and sponsorship--breaking down the image that the tobacco industry promotes of being useful, sporty and modern. And finally, raise taxes as high as possible. Taxes are very effective, especially among the poor and the young. The funding from taxes can be used for a number of programs. Currently only about 5 percent of the world's population has a tax rate over 25 percent of the package price. There's plenty of room for developed and developing countries to raise taxes.

Jonathan Samet: In the United States, the federal tax is around 67 cents a pack. Federal taxes are in general a small proportion of taxes in the states, which can levy some of them up to almost $3 a pack. We've begun to tax cigarettes far more than before. It's recognized as a source of revenue. It does have public health advantages. People are more likely to quit, and children are less likely to start.

Which countries are doing the best job?
Wipfli: Uruguay is the first country in the Americas to go completely smoke free. Ireland, Scotland, France and Italy have gone smoke free, everywhere, including restaurants and bars. A lot of countries have very large, graphic health warnings on packages, including in Thailand, Egypt, Uruguay, throughout the European Union. A number of other countries, including Malaysia, have increased their taxes. Thailand has very comprehensive tobacco-control laws, including strong bans on advertising. So does Poland. The United States is not the global leader.

Which countries have been resistant to implementing such policies?
Wipfli: Indonesia, Russia and the United States are among [them].

Should there be global campaigns against smoking in the same way there are now international HIV education and outreach programs?
Samet: There's not a one-size-fits-all here in terms of how to deal with the epidemic and how to slow it. There has to be an understanding of local issues. In India, for example, they use bidi, which is hand-rolled tobacco.

How much of a difference can WHO make? Isn't its budget tiny compared to the marketing budgets of most tobacco companies?
Samet: Certainly the tobacco industry collectively has spent billions of dollars on advertising and promotion. On the other hand, there's extraordinary power in the evidence on the epidemic, documenting how the industry uses advertising and marketing. To put this in perspective, there are far more resources available to WHO and other groups moving against the tobacco epidemic now than before. Yes, it's a bit of a David and Goliath story, but in this case, the tobacco control community has some pretty good weapons. That's in part what this MPOWER initiative is about.

Wipfli: WHO has just an incredible reach into countries, and it gets a lot of respect. Reports such as these coming out of WHO make a huge difference.

How do you think the tobacco companies undermine WHO efforts?
Wipfli: They do a number of activities to increase their access through investments and through corporate responsibility programs, through youth prevention programs. They are increasingly going into smokeless tobacco products. They're making shorter cigarettes that can be smoked during short smoking breaks. They continue to change their tactics. They continue to invest highly in advertising and promotion, and they're very politically savvy, through lobbying and foreign investment.

Samet: They've been particularly concerned about smoke-free legislation and have tried to oppose it in many states by enlisting the restaurant and hospitality industry as allies, who will claim that their revenues will be reduced. 

It's hard to believe that with all the research about the dangers of cigarette smoking--how it contributes to lung cancer, heart disease and other potentially deadly diseases--more than 1 billion people worldwide still smoke. Who still smokes and why?
Samet: About 1.3 billion people around the world still smoke. They're mostly men, a ratio of 4:1. One reason many smoke is they're addicted to smoking. They started at an age when they weren't aware of addiction. Even though in the United States, most people know the diseases that are caused not only by active smoking but passive smoking, people around the world often don't have that information at hand. Often it's culturally acceptable to smoke.

As Western governments take action to curb smoking, are tobacco companies just replacing lost smokers with new ones in developing countries?
Samet: There are a small number of very large companies like Philip Morris International, British American Tobacco [which owns brands like Lucky Strike and Pall Mall], and the world's largest is China National Tobacco. The industry has turned to the developing world to find markets. They're very large markets. China has 350 million smokers.

What about Africa?
Samet: Some of the companies are moving into the African market, like British American Tobacco.

With all the proven health hazards associated with smoking, does the rest of the world have a moral obligation to warn less educated targets of tobacco companies in developing countries?
Wipfli: Everyone has a moral obligation to warn the population about the harms of tobacco use. Last week Philip Morris International was spun off of Altria, the domestic U.S. company, and Philip Morris USA, [meaning it's now independent]. These companies now are close to state-less. They really don't have a government controlling them. They're very unregulated. While the government has a responsibility to act, the companies themselves want to remain beyond the reach of regulation.

Unchecked, WHO estimates that tobacco-related deaths will increase to more than 8 million a year by 2030, with 80 percent of the deaths in the developing world. Do you think you can reverse the trend?
Samet: [Already] 152 countries have agreed to the provisions, which provide a template for tobacco control. In the United States, cigarette smoking peaked in the 1960s. Percentage-wise we're down to 50 percent roughly of where peak smoking was. We know we can begin to curb tobacco use. The question is: how fast we can do it? It would be unfortunate if the developing countries had a new epidemic start, and the world did not move to prevent it.

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