In May 2017, just months before the end of her second term as Director-General of the World Health Organisation (WHO), Margaret Chan spoke about championing the WHO’s mission to fight tobacco use as one of her proudest achievements in office. What was surprising was the justification that followed. Dr Chan did not focus on the usual theme of health consequences associated with smoking. Instead, she declared that ‘tobacco is a deadly threat to global development’, affecting ’every country on every level and across many sectors – economic growth, health, education, poverty and the environment’ (Chan, 2017). The slogan ‘Tobacco – a threat to development’ became the theme of the 2017 World No Tobacco Day.
This was not the first time that tobacco has been recognised by the public health community as posing a threat ‘to the cause of social and environmental justice’, rather than just being a matter of individual health (Malone and Yang, 2017). In 2015, the magnitude of the tobacco epidemic was acknowledged in the 2030 Agenda for Sustainable Development (UN, 2015), encompassing 17 Sustainable Development Goals (SDGs). The need to strengthen tobacco control measures is directly referenced in SDG 3, but it is also highly relevant to the social, economic and environmental dimensions of sustainable development encompassed in several other SDGs (WHO, n.d.). Here we explore some key synergies between the SDGs and tobacco control, and point to a key obstacle to progress – the transnational tobacco companies (TTCs). We also highlight the importance of tobacco control networks for countering TTC interference, and of cross-disciplinary thinking for gaining a better understanding of the tobacco epidemic and how to arrest it.
SDG 3: Good Health and Well-Being
A key target of SDG 3 (Good Health and Well-Being) is ‘reducing premature deaths from noncommunicable diseases [NCDs] by one-third by 2030’ (Target 3.4). Tobacco use and exposure to second-hand smoke are leading risks of NCDs, responsible for a huge toll in morbidity, and accounting for over 7.2 million deaths annually (WHO, 2018a). This figure is projected to rise markedly, with WHO (2008) estimating a billion tobacco related deaths in the 21st century if current smoking rates persist. SDG target 3.3 ‘to end epidemics of (…) communicable diseases’ also links to tobacco, as its use weakens the immune system, exacerbating the risk of contracting infectious diseases such as tuberculosis and AIDS (McNeish, 2018).
Achieving the NCD reduction target goes hand in hand with another SDG target, (3.a), ‘to strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control [WHO FCTC] in all countries’. The FCTC, adopted in 2003, was the first binding multilateral treaty regarding NCDs. It covers the production, sale, distribution, advertisement, and taxation of tobacco, setting an evidence-based framework of minimum requirements for the signatory states in controlling tobacco products (WHO, 2003). The FCTC and – as at May 2019 – is currently legally binding in 181 ratifying countries. While in most high-income countries (HICs) the implementation of the FCTC has advanced markedly, in some low- and middle-income countries (LMICs) the progress has been much slower (WHO, 2017, Anderson et al., 2016). This is particularly alarming given that in 2018, four out of five smokers (or 880 million out of 1.1 billion smokers) lived in LMICs (WHO, 2018a).
SDG 1: End Poverty, and SGD 10: Reduced Inequalities within and among countries
Tobacco use globally tends to be highest among the poor and other vulnerable groups. In a study of 48 LMICs, poorest males were 2.5 times more likely to be smokers than their richest counterparts (Hosseinpoor et al., 2012). In fact, tobacco use has been found to exacerbate poverty and contribute to health and other inequalities within and between countries. When one or more members of household are tobacco consumers, more than 10 per cent of total household income is often spent on tobacco – money which could otherwise be used for necessities such as food, education, or health care (Chan, 2017). Smokers are also more likely to experience food insecurity (Kim and Tsoh, 2016).
Economists have pointed out that the global ‘economic burden of tobacco use is enormous and is increasingly borne by LMICs’ (NCI-WHO, 2016). In recent years, the increase in the number of smokers has been largely confined to countries with widespread poverty, particularly in Sub-Saharan Africa (SSA) (World Bank, 2017). Between 1990 and 2012, the demand for cigarettes increased by 44 per cent in 22 African countries, which was accompanied by a 106 per cent increase in cigarette production (Vellios Et al., 2018). It is estimated that by 2020, over 80 per cent of tobacco related deaths will occur in LMICs (NCI-WHO, 2016).
SDG 5: Gender Equality
Historically, smoking has been far more common among men than among women (Brandt, 2007). However, in recent decades we have seen this gap slowly eroding, with 27 per cent of all countries recording significant decreases in male daily smoking, versus only 16 per cent recording reductions for women. While this shift has been most pronounced in HICs, in some LMICs, including Russia and Indonesia, female daily smoking has significantly increased since 1990 (Reitsma et al., 2017). In many LMICs the epidemiological picture is less clear, as systems of public health surveillance are less developed, making it necessary to rely on modelling. Nonetheless, there is evidence suggesting that in certain low-income contexts, in particular in SSA, smoking rates among girls are significantly higher than among adult women (Blecher and Ross, 2013). With Africa’s demographic ‘youth bulge’ those trends could spell a public health catastrophe in the making.
SDG 12: Responsible consumption and production
The notion of responsible consumption is difficult to apply in the discussion of a product which, if used as intended by its producer, will kill half of all its users (WHO, 2018b). Nonetheless, the deleterious impact of cigarettes on the planet are far broader (Novotny and Zhao, 1999). Among them are the billions of cigarette butts disposed every day, which constitute one of the world’s leading environmental pollutants. They are the top item collected both in coastal clean-ups, with cigarette filters a major source of plastic waste in the oceans (Ocean Conservancy, 2018).
Tobacco growing and manufacturing have also been found to contribute to deforestation and soil degradation, in addition to being a source of agrochemical pollution (Lecours et al., 2012). Tobacco farming exposes the world’s 33 million tobacco farm workers, over 50 per cent of whom are women and minors, to a host of dangerous chemicals (Rowe, 2019, Hu and Lee, 2015, Otañez and Glantz, 2011). One common condition, green tobacco sickness, with a prevalence of 8.2 per cent to 47 per cent globally, is particularly prevalent among Asian and South American tobacco harvesters (Fotedar and Fotedar, 2017).
Copyright: WHO/Jan Brouwet
Challenges to effective tobacco control
Given the importance of stronger tobacco control measures in addressing the SDGs, and the overproportionate toll of tobacco on LMICs, why has the progress in adopting the FCTC been slower in LMICs? Part of the answer must be sought in the influence of the five tobacco companies that collectively control almost 90% of the world’s cigarette market (Callard, 2010). In the last decades, faced with stagnating or declining smoking rates in their traditional markets in HICs, and with well-organised public health networks using the FCTC to exercise pressure on policy-makers and governments for stricter regulation, the tobacco industry has turned its gaze towards LMICs as a source of future growth and main target for expansion (Brathwaite et al., 2015).
Research has revealed the myriad ways cigarette companies use to successfully oppose tobacco control regulation (for systematic overviews, see Ulucanlar et al., 2016, Gilmore et al., 2015, Savell et al., 2014, Smith et al., 2013). These include denying the health risks of smoking (Brandt, 2012), manufacturing doubt about the effectiveness of public health legislation (Oreskes and Conway, 2011), undermining sound science, and funding influential front and lobbying groups (Campbell and Balbach, 2008). The industry also has a history of targeting vulnerable groups with aggressive marketing efforts, and of dynamically building tobacco consumption in markets with previously low smoking rates (Connolly et al., 2010, Lee et al., 2009). For example, in settings with low social acceptability of female smoking, i.e. in parts of Africa, Eastern Europe, South-East Asia, the tobacco companies pursued culturally attuned marketing campaigns to draw women to smoking (Hitchman and Fong, 2011). Furthermore, in countries with high poverty rates they captured the market by offering very cheap cigarettes and selling single sticks (ACTA, 2018). When governments of smaller LMICs sought to introduce evidence-based tobacco control policies, for example on plain packaging, the TTCs have threatened them with lawsuits and international tribunals in numerous cases (Gilmore et al., 2015, Boseley, 2017).
In some of the world’s poorest countries, in particular in SSA, TTCs have forcefully pushed for the development of tobacco farming, presenting it as an economic and development opportunity (Hu and Lee, 2015). Millions of farmers were convinced to focus on tobacco cultivation, becoming reliant on tobacco industry custom, and strengthening the hand of the TTCs in lobbying against legislation in those countries (Hu and Lee, 2015). In practice, however, instead of lifting farmers out of poverty, tobacco cultivation has been found to often lead them to accrue loans which they are unable to repay (Agonda Ochola and Kosura, 2007), and rely on government subsidies (Hu and Lee, 2015), while large buyers control supply chains (Callard, 2010).
The importance of strengthening tobacco control networks and cross-disciplinary thinking
Despite the aggressive move of the TTCs into LMICs, to date the bulk of the existing research on exposing and countering tobacco industry tactics has been focused on high-income settings. Some of the existing research suggests that the TTCs use broadly similar tactics in opposing regulation globally (Gilmore et al., 2015, Lee et al., 2012). However, in-depth case studies of LMICs have revealed the industry’s ability to tailor its behaviour to exploit local specificities in LMICs (for example, Kohrman et al. ,2018 on China, Egbe et al., 2017 on Nigeria, Gilmore and McKee 2004) on the former Soviet Union, Neuburger (2012) on Bulgaria, Szilagyi and Chapman (2004) on Hungary).
Perhaps even more importantly, research has shown that successful tobacco control advocacy, and the successful implementation of FCTC provisions in LMICs, is based on a combination of a good knowledge of local context, and the ability of advocates to tap into existing international tobacco control networks (for example, Crosbie et al., 2018, Uang et al., 2018, Crosbie et al., 2017, Zatoński, 2016, da Costa e Silva et al., 2013). Much progress has been made in recent decades in strengthening these networks, and, more broadly, in building a cohesive an international epistemic tobacco control community (Mukherjee and Ekanayake, 2009). Using these networks to strengthen tobacco control in LMICs, through capacity building, developing international collaborations, and fostering local leaders, advocates and researchers, and enabling them to draw on the vast pool of experiences and case studies from around the world, should remain a key objective on the global public health agenda (Berg et al., 2018, Hipple Walters et al., 2018, Namusisi Nyamurungi et al., 2018). This also resonates closely with SDG 17, which aims to strengthening global partnerships that support the achievement of the Sustainable Development Agenda.
Global tobacco control networks need to be sustainable, since adopting legislative measures is only the first step, with their implementation and enforcement equally – if not more – important. Crucially, they also need to cross disciplinary boundaries, going far beyond just a collaboration of tobacco control advocates and researchers. Most pressingly, given the growing challenge posed by tobacco to LMICs, a more active engagement needs to be developed with development studies scholars. Their expertise on topics like corporate social responsibility, global supply chains and local livelihoods, informal economies, civil society, governance and corruption, as well as their often in-depth and intimate knowledge of local contexts, can be crucial in informing effective strategies to oppose corporate actors seeking to undermine effective public health policies in LMICs.
Tobacco Control Research at Bath: With international partners, the Tobacco Control Research Group within the Department for Health has been awarded major funding from Bloomberg Philanthropies to lead a new global tobacco industry watchdog called STOP (Stopping Tobacco Organizations and Products). The project runs until late 2021 with James Copestake (SPS), Michael Bloomfield (SPS) and Britta K. Matthes (Health), three members of the CDS, contributing research in support of the STOP project.
We would like to thank James Copestake, Michael Bloomfield, Lindsay Robertson and Dara O'Hare for their comments.