1. Tobacco Control and the Role of Government
Rekha Menon
Senior Economist, Human Development Unit
Eastern Europe and Central Asia
World Bank
Tashkent, Uzbekistan
December 13, 2007
In the ECA region and the rest of the world, there are millions of deaths and a huge burden of disease caused by tobacco use. Despite this, many governments have been afraid to try to discourage smoking, because they fear that the economy might suffer.
A few years ago, the World Bank asked a group of expert economists to look carefully at the facts and the evidence to answer the question: "What is the economic impact of tobacco control?" A wealth of evidence, research and facts are clearly summarized in "Curbing the Epidemic: governments and the economics of tobacco control", published by the World Bank in English in 1999 (in Washington DC), and now, in May 2001, published in several languages, including Russian, Polish, Hungarian, Turkish for the World Bank. The "bottom line" of the study is that tobacco control could save millions of lives, without damage to most economies.

2. Why is Tobacco Control a Priority for Governments?

3. Globally, 80,000 to 100,000 youths start smoking every day
1.2 billion smokers worldwide, 984 million (82%) smokers in developing countries.
Globally, 80,000 to 100,000 youths start smoking every day
Smokers often do not know the risks
Tobacco is addictive and difficult to quit
About 1.2 billion people smoke worldwide.
By 2025, the number is expected to rise to more than 1.6 billion. In the high-income countries, smoking has been in overall decline for decades. In low- and middle-income countries, by contrast, cigarette consumption has been increasing – total smokers = global youth population under 15.
4.9 million deaths this year, growing to ten million deaths annually by more than the total deaths from malaria, tuberculosis, maternal and major childhood conditions combined. Smoking-related deaths used to be concentrated in high-income countries. But this is changing fast. By 2020, seven million of the ten million deaths will occur in developing countries, including here, in Hungary.
Most smokers start young. In the high-income countries, about eight out of 10 begin in their teens. While most smokers in low- and middle-income countries start in the early twenties, the peak age of uptake in these countries is falling. Globally it is estimated that everyday 80,000 to 100,000 youth start smoking.
Smokers clearly perceive benefits from smoking, such as pleasure and the avoidance of withdrawal, and weigh these against the private costs of their choice.
But there is evidence that many smokers are not fully aware of the high risks of disease and premature death from tobacco use.
Tobacco is addictive and it is difficult to quit without help.

4. High disease burden….
Second major cause of death worldwide and fourth most common risk factor for disease worldwide
4.9 million deaths in 2000 and 56% of tobacco disease burden is in developing countries
By 2030, tobacco is expected to be the single biggest cause of death worldwide, accounting for about 10 million deaths per year

5. High economic costs often as high as 1.1% of GDP…
Premature mortality
Health care costs related to smoking induced chronic diseases (affect non-smokers as well)
Forgone earnings
Productivity loss especially for poor

6. How important an issue is tobacco control Eastern Europe and Central Asia?

7. High smoking prevalence
Tobacco epidemic is rapidly emerging in the ECA region, faster than any other region in the World. 12% of the world’s smokers live in the ECA region. Most smokers start early, ECA is not an exception, but youth become heavy smoker much faster in the ECA region. More and more countries in the ECA region are implementing tobacco control measures, but they are either not enough or implemented ineffectively. The World Bank has been supporting tobacco control research and projects but given the seriousness of the epidemic in the region, still more needs to be done.
Almost all smokers in the ECA region, especially men are hooked to smoking. Women has been following their counterparts in developed countries by picking up smoking in the region. More than half of the male population are smoker in Bulgaria, Armenia, Turkey, Latvia, Belarus, Slovakia, Georgia, Kyrgyz Rep. And Russian Federation. Prevalence has been increasing in most of these countries.

8. Smoking prevalence in Uzbekistan
Smoking Prevalence by Sex and 35+ age group (%)
Never
Current
Former
Ever
Male 52 29 19 48
Female 98
1.1
0.7
1.8
Total male
1,907,688
1,069,629
698,383
1,767,355
Source: Household Budget Survey, 2006 Uzbekistan

9. Heavy smokers in Uzbekistan
Source: Household survey, Uzbekistan

10. Smoking starts early and is addictive
Smoking starts early. When the youth smoking prevalence is examined in ECA countries, there is a horrifying picture. In 1995, 56% and 21% of 14 to 16 yrs old boys and girls were smokers in Armenia. Similarly, in 1996, 14% of 7 to 13 years old boys and 9% of 7-13 yrs old girls were smoker in Turkey. Similar pictures can be seen in Belarus, Bulgaria, and Hungary where the data is available. These kids are the future adult smokers.
Source: WHO

11. Youth are heavy smokers…
Youth in ECA region does not only start smoking early, but also become heavy smokers at their youth. In 1999, 13% of 16 year olds were smoking 6 to 10 cigarettes a day in Bulgaria and 3% of 16 year old kids smoked 21 cigarettes a day. That level is much higher than adult consumption level in other parts of the world.

12. Higher cigarette consumption
Smokers in ECA region smoked 16.3% of the world cigarette consumption where only 8% of the world population lives.
Source: World Bank estimation

13. High average consumption per smoker….
On average smokers in Romania, Bulgaria, Poland and Czech Rep. smoke more than a pack per day.
Source: World Bank staff estimates

14. Tobacco attributable deaths in Central Asia
In Central Asia, smoking was responsible for 34% of total deaths in Kazakhstan, 19% in Kyrgyz Rep., 13% in Uzbekistan, 6% in Tajikistan, and 12% in Turkmenistan in During , smoking related deaths increased in Kazakhstan, Kyrgyz Rep., and Uzbekistan.

15. Male Lung Cancer Mortality in Selected Countries
Age standardized rate/100,000
Tobacco is responsible more than 96% of lung cancer deaths. In ECA region, lung cancer mortality among men has been increasing and predicted to be increasing in the future, in Bulgaria, Former Yugoslavia, Romania, and Hungary. Given the high prevalence and level of smoking, this is not surprising.
Source: International Agency for Research on Cancer

16. What can Government’s do?

17. Deter children and youth from smoking
Give adults all the information they need to make an informed choice
Interventions that control demand are more effective
than supply side interventions

18. Higher cigarette taxes – most cost-effective measure
Non-price measures:
Increase consumer information: dissemination of research findings, warning labels, counter-advertising
Comprehensive ban on advertising and promotion
Restriction on smoking in public and work places
Cessation help (NRT)
There is clear evidence to show what works, and what doesn’t in reducing tobacco use. The evidence from many countries points clearly to a set of tobacco control measures that are effective and very cost-effective in reducing the demand for tobacco products.
Raising cigarette taxes is the most cost-effective measure to reduce cigarette consumption.
In addition to raising the price, there are a range of other effective measures that governments could employ. These include comprehensive bans on advertising and promotion of tobacco; information measures such as mass media counter-advertising, prominent health warning labels, the publication and dissemination of research findings on the health consequences of smoking as well as restrictions on smoking in work and public places and increased access and affordability for nicotine therapy products and other cessation therapies.

19. Higher taxes - impact on consumption…
Cigarette taxation will reduce cigarette sales
Increasing price is the most effective means of decreasing cigarette smoking, especially among children, adolescents and young adults.
10% price increase will decrease cigarette consumption 4% in developed countries, 8% in developing countries.
Smoking among children will fall by about twice as much.
Source: Chaloupka et al., Ch. 10 in Jha and Chaloupka, 2000

20. As taxes increase, consumption decreases
-0.4 for dev, -0.8 for developing

21. Impact of prices on consumption in Uzbekistan…
Tax increase  price increase influences stronger poorer population from rural areas

22. Higher taxes - impact on revenue….
Increased taxes invariably increase government revenues.
The percentage decline in cigarette consumption is smaller than the percentage increase in price that induces it.
Further, tax is only a fraction of price, so a given tax increase will cause a far smaller decrease in cigarette sales.

23. Higher taxes - impact on the poor….
Cigarette taxes are regressive.
A larger proportion of the poor smoke.
However, a tax increase may produce a progressive impact
because the rich decrease their smoking only slightly in response to a price increase
the poor decrease theirs substantially.
[Townsend et al., BMJ, 1994]

24. Furthermore….
Health benefit of a tax increase is distinctly progressive.
Countries can compensate in part for any tax regressivity
e.g., by funding cessation services and pharmaceuticals for poor smokers.

25. Control smuggling through law enforcement…
Effective control measures of smuggling exist
Focus on large container smuggling
Prominent local language warnings and tax stamps
Increase penalties
Licensing and tracking of containers
Increase export duties or bonds
Multilateral tax increases help combat smuggling
Nicotine treatment therapies have a particular importance. There are 1.1 billion smokers around the world who are addicted to nicotine. Evidence show that large numbers of smokers want to quit smoking and have tried at least once to quit.
It is important to help those who want to quit. Nicotine replacement therapy (NRT) and other cessation interventions markedly increase the effectiveness of cessation efforts and also reduce individuals’ withdrawal costs. Yet in many countries, NRT is difficult to obtain. If NRT were more widely available, it could help to reduce demand substantially.
Evidence also shows that advice from health professionals to patients to quit can make a substantial difference, but there is also a clear need in many countries to reduce the number of smokers among health professionals themselves.

26. Health information reduces the demand for cigarettes
Source: Kenkel and Chen, 2000

27. Comprehensive advertising bans reduce cigarette consumption Consumption trends in countries with bans vs. no bans (n=102 countries)
Source: Saffer, 2000

28. Restrict smoking among youth, in public & at workplaces
Clean indoor-air laws:
can reduce cigarette consumption
can be self-enforcing
work best with social consensus against smoking
reduces negative impact of second hand smoking
Youth access restrictions:
mixed evidence of effectiveness
require aggressive reinforcement

29. Support cessation treatments
Cessation support from health professionals is key
NRTs double the effectiveness of cessation efforts
Quit lines, community support, etc., work
Governments may increase accessibility and affordability of NRTs by:
Over the counter (OTC) sales, allowing advertising, licensing
Conducting more studies on cost-effectiveness (especially in low/middle income countries)
Considering NRT subsidies for poorest smokers
Nicotine treatment therapies have a particular importance. There are 1.1 billion smokers around the world who are addicted to nicotine. Evidence show that large numbers of smokers want to quit smoking and have tried at least once to quit.
It is important to help those who want to quit. Nicotine replacement therapy (NRT) and other cessation interventions markedly increase the effectiveness of cessation efforts and also reduce individuals’ withdrawal costs. Yet in many countries, NRT is difficult to obtain. If NRT were more widely available, it could help to reduce demand substantially.
Evidence also shows that advice from health professionals to patients to quit can make a substantial difference, but there is also a clear need in many countries to reduce the number of smokers among health professionals themselves.

30. In summary….
Adopt a multi-pronged strategy, tailored to the country needs
Excise taxes on cigarettes to reduce consumption
Help current smokers by increasing access to cessation therapies – can be funded from tax revenues
Increase health professionals’ awareness and information, on tobacco related issues
Increase tobacco control measures, ban advertising and promotion, restrict smoking in public and work places, restrict youth access to tobacco products, etc.
Increase consumer information and tobacco control projects.
Governments should adopt comprehensive tobacco control policies which are tailored to each country.
Bans on smoking in workplaces and public spaces, comprehensive bans on advertising and promotion of tobacco products, better information to educated and uneducated population, health professionals, and consumers, and large and strong health warnings on packages all help reduce smoking significantly. Governments should support tobacco control projects to help smokers and smokers to be.

31. Main stakeholders Customs Administration: Smuggling, Border Control
Ministry of Finance: Tobacco Tax Revenues
Customs Administration: Smuggling, Border Control
Ministry of Labor: Farmers and Manufacturing Labor
Ministry of Agriculture: Tobacco Production
Ministry of Education: Youth education on tobacco
Smokers: Low prices, variety and appealing products
Producers: Profit, market share, sales
Ministry of Trade: Export earnings from tobacco