Tobacco tightrope – Balancing disease prevention and development

FRIDAY-SPOTLIGHT: Tobacco tightrope – Balancing disease prevention and development

Published in: The New England Journal of Medicine----------

[THE RIPPLE EFFECTS ARE PAINFULLY VISIBLE: BECAUSE CHINA HAS NO NATIONAL HEALTH CARE SYSTEM AND LITTLE PRIVATE HEALTH INSURANCE, MANY CHINESE PEOPLE GO BANKRUPT TAKING CARE OF SICK FAMILY MEMBERS] please read more below...

During the past 20 years, as smoking rates have fallen in high-income countries, the tobacco industry has found new and bigger markets in the developing world. One third of current smokers live in China — more than in the United States and all European countries combined.

The World Health Organization (WHO) predicts that 70% of the deaths from smoking-related illnesses will occur in low- and middle-income countries by 2020. Smoking is likely to have a particularly devastating effect on China, where the annual death toll from smoking-related diseases already exceeds 1 million — 2.5 times that in the United States — and is expected to double by 2025 if smoking rates are not reduced.1 The ripple effects are painfully visible: because China has no national health care system and little private health insurance, many Chinese people go bankrupt taking care of sick family members. "With other health problems," says Kathryn Mulvey, executive director of the nonprofit organization Corporate Accountability International, "you've got rats or mosquitoes, but in this case the tobacco industry is the vector of disease."

The Chinese tobacco epidemic will soon encounter some new resistance —oddly enough, from the owner of the largest cigarette monopoly in the world: the Chinese government. In 2005, China ratified the WHO Framework Convention on Tobacco Control. To date, 145 countries,
representing more than 80% of the world's population, have ratified this first international public health treaty, which took effect in February 2005 (see map). The treaty aims to regulate tobacco companies' actions, using proven strategies: raising taxes on tobacco products, limiting smoking in public, requiring new health warnings on cigarette packages, and regulating the firms' manufacturing and marketing efforts. China's surprising decision to ratify the treaty has won it influential friends in the global tobacco-control community.

One international program that will be investing heavily in China is the new $125 million Bloomberg Global Initiative to Reduce Tobacco Use, funded by New York City Mayor Michael Bloomberg. Bloomberg has tapped Judith Mackay, a Hong Kong–based physician and senior policy advisor to the WHO, to help coordinate his efforts.

Mackay's longtime leadership in the fight against transnational tobacco companies has earned her the fear of such major players as British American Tobacco, which once named her one of the three most dangerous people in the world. She was instrumental in crafting the WHO treaty, and she will now be able to help Asian countries implement it. Because the Bloomberg initiative has doubled the available funding for tobacco control in low- and middle-income countries at this critical moment, many people see it as a crucial catalyst for translating international law into action.

Although sobering statistics have turned many low- and middle-income countries into advocates of strict regulation, some wealthier countries, such as the United States, have remained ambivalent. Throughout the 4 years of negotiations preceding the World Health Assembly's unanimous adoption of the treaty in 2005, U.S. objections were often closely aligned with the interests of the tobacco industry. "In the third round of negotiations, Philip Morris prepared a wish list for the treaty, and the Bush administration took 10 out of 11 of their positions," said Mulvey.

"The United States fought tooth and nail against a ban on tobacco advertising and sponsorship. It was really clear that a few wealthy nations with close ties to the tobacco industry were holding back countries that wanted to embrace strong policies." Other observers, including Derek Yach, former head of the WHO's tobacco-control initiative, argue that the position of the United States is much more complex. It's easy to blame the conservative Bush administration, "but the United States has always been wary of international treaties," Yach explains.

During negotiations, "there was a constant tension between the State Department, which wanted less engagement, and the Health Department, which wanted more." In 2004, Secretary of Health and Human Services Tommy Thompson announced that the United States had adopted the treaty without reservation, but Congress has yet to ratify it. Some say the State Department has prevented congressional debate on the treaty by holding it hostage "under review": approval by two thirds of the Senate is required for ratification, but the Bush administration hasn't sent the treaty to the Senate for a vote.

Matt Myers, president of the Campaign for Tobacco-Free Kids, an advocacy organization and partner in the Bloomberg initiative, argues that special interests have intervened: "A majority of members of both the House and Senate are supportive of tobacco-control efforts. That leaves the unmistakable impression that the Bush administration is simply giving in to pressure from tobacco companies." Ironically, many poorer countries that, like China, rely on tobacco for economic growth have ratified the treaty.

When China joined the World Trade Organization in 2001, it obtained a special exemption to maintain its monopoly, China National Tobacco, which produces 1.8 trillion cigarettes annually.2 Although China agreed, in principle, to phase out quotas on imports, it also began a radical restructuring of its industry, centralizing manufacturing, limiting the number of brands in an effort to build brand loyalty, and quietly expanding its sales abroad.3 As international pressure to cut tobacco use mounts, the Chinese government struggles to balance advancing the country's economy with maintaining the health of its society and garnering global support.

In 2005, cigarette sales generated $32.5 billion in taxes and profits in China, approximately 7.6% of the government's total revenue. In contrast, the government spent $31,000 on tobacco control. Tobacco remains a pillar of the Chinese economy: consumers spend more on cigarettes than on alcohol or personal care products.

Moreover, tobacco is seen as key to economic growth in the more remote, poorer sections of the country, such as Yunnan province, whose government depends on tobacco sales for more than 50% of its revenues. The health effects of smoking are commonly downplayed in China, even by those in key political positions. Half of all male Chinese doctors smoke, as do some politicians. Even a few Chinese tobacco-control advocates express mixed feelings about promoting the use of graphic warning labels on cigarette packages, recognizing that ugly pictures would mar the packs traditionally given as presents to wedding guests.

At the same time, tobacco-control experts fear that Chinese women and children will begin to smoke if transnational tobacco manufacturers gain a foothold in the country. Currently, only 3% of women and 10% of middle-school children smoke, but international manufacturers are already targeting these populations. Mulvey of Corporate Accountability International argues that tobacco companies are manipulating Western images of independence to seduce teenagers and increasingly liberated women in developing countries.

Such marketing can be frighteningly effective: when South Korea opened its markets to American cigarettes, the rate of smoking among teenage girls quintupled in 1 year, and the rate among adolescent boys doubled.4 Billions of foreign cigarettes are already smuggled into China each year, but recently, candy-flavored cigarettes have become one of the most popular illegal imports.

Public health experts describe these as "starter cigarettes" aimed at children. As a competing manufacturer, China has already responded by producing its own fruit-flavored cigarettes. Western tobacco companies have been eager to make further inroads into China's market. In 2005, Philip Morris joined forces with China National Tobacco to market Marlboro cigarettes in the country. Other brands, such as Camel, Lucky Strike, and Kool, have also been sold. Although foreign brands have garnered only 3% of the Chinese market, that amounts to 51 billion cigarettes per year. By signing on to the WHO's mandate, China agreed that by 2008, clear health warnings would occupy more than 30% of the surface of every cigarette pack sold. It is already technically illegal in China to promote tobacco on billboards or in magazines, and all forms of advertising will be banned by 2010.

There are also plans for a "smoke-free Olympics" in 2008, and some tobacco-control advocates hope that the cities hosting the Olympics will become smoke-free forever. Hong Kong has already outlawed smoking in public places, as of January 2007. Some skeptics fear that it may be too late to quell the tobacco epidemic in many developing countries. Even the most optimistic observers recognize that it will take at least a generation of hard work to see real change. In the meantime, millions more people will lose their lives to tobacco-related diseases, and low-income countries will need to come to grips with the devastation that tobacco can wreak. -------------

Alexi A. Wright, M.D., and Ingrid T. Katz, M.D., M.H.S. (Dr. Wright is a fellow in hematology–oncology at the Dana–Farber Cancer Institute, Boston, and Dr. Katz is a fellow in infectious disease at the Beth Israel Deaconess Medical Center, Boston)

Available online at: http://content.nejm.org/cgi/content/full/356/15/1493?query=TOC