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Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015

Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015

http://thelancet.com/journals/lancet/article/PIIS0140-6736(17)30819-X/fulltext?elsca1=tlpr

Summary

Background

The scale-up of tobacco control, especially after the adoption of the Framework Convention for Tobacco Control, is a major public health success story. Nonetheless, smoking remains a leading risk for early death and disability worldwide, and therefore continues to require sustained political commitment. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, and national progress toward achieving smoking-related targets can be assessed.

Methods

We synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimates of daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed 38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured by disability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohort to better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed out changes in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smoking prevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using the Socio-demographic Index (SDI).

Findings

Worldwide, the age-standardised prevalence of daily smoking was 25·0% (95% uncertainty interval [UI] 24·2–25·7) for men and 5·4% (5·1–5·7) for women, representing 28·4% (25·8–31·1) and 34·4% (29·4–38·6) reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualised rates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countries had significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] and Azerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11·5% of global deaths (6·4 million [95% UI 5·7–7·0 million]) were attributable to smoking worldwide, of which 52·2% took place in four countries (China, India, the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries and territories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followed similar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for female smokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex and SDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smoking-attributable DALYs in low-SDI to middle-SDI geographies between 2005 and 2015.

Interpretation

The pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking’s global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, and adequately implemented and enforced policies, which might in turn require global and national levels of political commitment beyond what has been achieved during the past 25 years.

Funding

Bill & Melinda Gates Foundation and Bloomberg Philanthropies.

Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015

Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015

http://thelancet.com/journals/lancet/article/PIIS0140-6736(17)30819-X/abstract

Summary

Background

The scale-up of tobacco control, especially after the adoption of the Framework Convention for Tobacco Control, is a major public health success story. Nonetheless, smoking remains a leading risk for early death and disability worldwide, and therefore continues to require sustained political commitment. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, and national progress toward achieving smoking-related targets can be assessed.

Methods

We synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimates of daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed 38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured by disability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohort to better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed out changes in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smoking prevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using the Socio-demographic Index (SDI).

Findings

Worldwide, the age-standardised prevalence of daily smoking was 25·0% (95% uncertainty interval [UI] 24·2–25·7) for men and 5·4% (5·1–5·7) for women, representing 28·4% (25·8–31·1) and 34·4% (29·4–38·6) reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualised rates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countries had significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] and Azerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11·5% of global deaths (6·4 million [95% UI 5·7–7·0 million]) were attributable to smoking worldwide, of which 52·2% took place in four countries (China, India, the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries and territories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followed similar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for female smokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex and SDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smoking-attributable DALYs in low-SDI to middle-SDI geographies between 2005 and 2015.

Interpretation

The pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking’s global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, and adequately implemented and enforced policies, which might in turn require global and national levels of political commitment beyond what has been achieved during the past 25 years.

Funding

Bill & Melinda Gates Foundation and Bloomberg Philanthropies.

Cancer group renews push to increase tobacco purchase age to 21

Cancer prevention advocates are renewing their push to raise the statewide smoking age from 18 to 21.

The issue has been raised before, as a growing number of cities and towns increase the age for purchasing tobacco. A bill to raise the statewide tobacco purchase age to 21 passed the Senate last year on a vote of 32-2. But the bill never made it through the House.

Carol Clark, a volunteer with the American Cancer Society Cancer Action Network from Gloucester, survived cancer herself. She has two friends currently battling lung cancer caused by smoking. She lost her grandmother to smoking-related emphysema. She plans to come to the Statehouse to lobby for the bill.

“I think kids have too much access (to tobacco),” Clark said. “They start smoking at a young age. It does major damage.”

Clark said she does not understand why so many teenagers start to smoke given the information available today about its health risks. Clark, 61, said she wishes that information was available when her generation and her parents’ generation were growing up.

“I don’t want to see the next generation go through what mine are going through right now,” she said.

According to the American Cancer Society, 95 percent of smokers start smoking before age 21. Supporters of the bill see it as a way to protect children and teenagers and avoid negative public health impacts, including an increase in cancer rates, later on. It would also create uniform rules across the state, as opposed to a patchwork of local ordinances.

Opponents of the bill have argued that 18-year-olds are adults and should be allowed to make their own decisions. And raising the age could negatively affect businesses that sell tobacco.

The penalties for violating the law would be on retailers, not smokers.

Other sections of the bill would ban the sale of tobacco in pharmacies and ban the smoking of e-cigarettes in schools, restaurants and workplaces.

The American Cancer Society Cancer Action Network will be advocating for the bill as part of its annual lobbying day at the Statehouse on Wednesday. The group expects more than 100 people at the event.

The legislation, S.1218/H.2864, is sponsored by Sen. Jason Lewis, D-Winchester, and Rep. Paul McMurtry, D-Dedham. It has approximately 140 co-sponsors.

How Trump Ally Myron Ebell Spread Misinformation for Big Tobacco and Big Oil

The former head of President Trump’s EPA transition team played a central role in the corporate-led attack on public perceptions about tobacco and climate change.

http://www.alternet.org/environment/how-trump-ally-myron-ebell-spread-misinformation-big-tobacco-and-big-oil

“Frontiers will [change] the debate from one about teenage smoking and industry practices to one about massive tax increases, bigger government and loss of individual freedom.” — Frontiers of Freedom funding proposal to Philip Morris

When Phillip Morris didn’t like new FDA regulations that targeted cigarette sales to children and teens, Myron Ebell—who recently served as the head of President Trump’s EPA transition team—was there to “change the debate” to fit the tobacco giant’s agenda.

The FDA’s proposed regulations included prohibiting outdoor advertising of any tobacco products near schools or playgrounds, strictly regulating labeling and prohibiting tobacco company sponsorships of public events. To fight the new restrictions, tobacco-industry-funded Frontiers for Freedom started a campaign to cast doubt on the validity of the new regulations.

Frontiers, a conservative “educational foundation,” hired Ebell as policy director to help run the campaign, even using his name to raise money for the project. In a fundraising letter to Philip Morris in 1998, Frontiers highlighted Ebell as an example of why more funding was needed to run an organized push to make regulating the tobacco industry “politically unpalatable.”

The Frontiers campaign was pure spin. The tobacco companies’ First Amendment rights were being trampled on, it claimed—more Big Government overreach. From pushing the dubious claim that rules infringed on smokers’ and tobacco companies’ rights to blaming smokers themselves, Ebell oversaw Frontier’s tobacco-industry-funded drive to fight regulation. It took a fourteen-year battle for Congress to pass the regulations and make them stick. In the end, the tobacco advertising regulations made significant progress in curbing teen smoking. No thanks to Ebell and Frontiers for Freedom.

In April of 1998, Ebell and a handful of other marketing experts sat around a table with some of the largest U.S. fossil fuel companies to discuss a plan for a similar attack on climate science. Representatives from Exxon, Chevron, utility giant Southern Company and the American Petroleum Institute worked with operatives from established conservative think tanks and public relations wonks to draft a program designed to attack public and political perceptions about climate change. They dubbed it “The Global Climate Science Communications Plan.”

The plan’s strategy was similar to Frontier’s anti-regulation tobacco campaign. This time the goal was to make climate-change-related regulation politically unpalatable.

The foundation of the plan was to sow doubt about the scientific validity of action on climate change, even though in 1998 the science was already solid. Of the ninety-six papers published on global warming that year, just one disagreed about man’s activities driving warming. That truth about the state of the science was replaced with a push to convince “a majority of the American public” that “significant uncertainties exist in climate science.”

The seven-page directive boldly stated that “victory will be achieved when” the uncertainties about climate science are part of “common knowledge,” when media recognizes and covers those uncertainties and when those promoting action on climate science appear out of touch.

Strategies and tactics of the plan included:

• Recruit and train a team of scientists for media outreach
• Produce a steady stream of op-eds written by these scientists
• Organize and teach conservative grassroots groups
• Become a one-stop-shop for members of Congress, state leaders and teachers looking for information about climate change
• Distribute materials directly to schools and convince a national TV journalist to produce a TV program outlining the supposed uncertainties

It worked.

In 2007, television journalist John Stossel did a bang-up job promoting climate confusion with his special, “Myths, Lies and Downright Stupidity,” for a special edition of “20/20.” By 2016, a Pew poll found only 9 percent of conservative Republicans believed that climate research reflects the best available evidence, while 57 percent of that same group felt that climate research is influenced not by valid science, but by scientists’ desire to advance their careers.

In 1999, Ebell moved to Competitive Enterprise Institute, a libertarian think tank funded by many of the same oil companies he’d sat around the table with the year before to hatch the plan to misinform the American public. From 1998 to 2005, ExxonMobil provided CEI with over $2 million dollars of funding. As director of CEI’s Center for Energy and Environment, Ebell put the plan to work.

Impacting the voice of elected officials was another key aspect of “victory” named in the 1998 disinformation plan. By that measure success was swift in coming. Just two years after the plan was hatched, CEI joined with conservative Senator James Inhofe as co-plaintiff in a lawsuit over the National Assessment, a federal report on climate change’s impacts on the United State.

The lawsuit was designed to suppress publication and distribution of recent climate science findings. In 2003, CEI sued the U.S. government directly, demanding the National Assessment not be disseminated. In 2005, Senator Inhofe joined with Ebell and other climate science deniers on a speaker’s panel for a CEI panel to discuss the Future of International and U.S. Climate Policy. By 2012, Ebell was bragging on his blog about Inhofe’s legislation to block EPA regulations. It was a victory: Climate-change-related regulation had become politically unpalatable.

Opposition to the validity of climate science skyrocketed among conservative politicians after 1998. Fighting all government action on global warming is now a bullet point on the GOP’s purity test. Over that same period, oil industry financial support for political campaigns and lobbying efforts have overwhelmingly gone to Republicans.

The election of Donald Trump was icing on the climate science denial cake. Ebell was tapped to head Trump’s EPA transition team. Eighteen years of work deceiving the public finally paid off for Ebell. His dream of drastically reducing the power of the EPA is being realized. Ebell headed Trump’s EPA transition team. He oversaw the writing of a policy paper—not available to the public—that will steer fellow climate science denier and EPA antagonist-turned-EPA head Scott Pruitt. Under Pruitt’s leadership, climate-change-related regulations will be rolled back and the EPA’s budget will be cut by 24percent.

Ebell has no background in science. He studied philosophy and has a master’s degree in political theory. His understanding of modern climate science sounds like this:

The models say that much of the warming will occur in the upper latitudes and in the winter. At the risk of further ridicule in kooky blogs in England, where global warming alarmism is now a religion, that sounds pretty good to me. Fewer people will die from the cold.

Fossil fuel industries got what they wanted. Conservative politicians got what they wanted. CEI got what it wanted. Ebell got what he wanted. All at the expense of the environment, public health and the stability of future generations.

Hope Forpeace is a short film producer with AK Productions. She spoke before the EPA’s Scientific Advisory in 2015 and coordinated the effort to have EPA’s fracking study include known cases of water contamination. She has traveled across the country for several years investigating cases of fracking-related pollution.

Cancer Activists Push Bill to Hike Legal Age to Buy Tobacco

Over 100 cancer patients, survivors and their families from across Massachusetts are planning to gather at the Statehouse to press lawmakers to support efforts to protect young people from nicotine addiction.

http://www.capecod.com/newscenter/cancer-activists-push-bill-to-hike-legal-age-to-buy-tobacco/

At the top of the agenda is a bill that would increase the legal age to buy tobacco products from 18 to 21.

The legislation would also include e-cigarettes in the smoke-free workplace law and ban the sale of tobacco products in facilities that provide health care, such as pharmacies.

About 95 percent of adults who smoke started by age 21.

More than 140 communities in the Commonwealth have passed regulations raising the purchase age from 18 to 21, including Falmouth, Mashpee, Yarmouth, Brewster, Orleans, Eastham and Provincetown.

The Board of Health in Harwich will hold a public hearing April 11 to discuss a proposed regulation change to increase the legal age to 21. The board could vote on the measure that night.

Wednesday’s visit to Beacon Hill is part of the American Cancer Society Cancer Action Network’s annual lobby day.

This year, an estimated 37,000 Massachusetts residents will be diagnosed with cancer. An estimated 12,600 will die from the disease.

Progress against ‘global tobacco epidemic’ made but not enough

Tobacco treaty has helped cut smoking rates, yet more work is needed

http://www.timesofmalta.com/articles/view/20170325/health-fitness/Progress-against-global-tobacco-epidemic-made-but-not-enough.643389

The WHO warns against tobacco use which kills about six million people a year globally and imposes a huge burden on the world economy.

A global tobacco treaty put in place in 2005 has helped reduce smoking rates by 2.5 per cent worldwide in 10 years, researchers said, but use of deadly tobacco products could be cut even further with more work on anti-smoking policies.

In a study published in the Lancet Public Health journal, researchers from Canada’s University of Waterloo and the World Health Organisation (WHO) found that while progress against what they called the “global tobacco epidemic” has been substantial, it has still fallen short of the pace called for by the treaty.

The WHO Framework Convention on Tobacco Control (FCTC), which came into effect in 2005, obliges the 180 countries signed up to have high tobacco taxes, smoke-free public spaces, warning labels, comprehensive advertising bans and support for stop-smoking services.

Smoking causes lung cancer and is a major risk factor for cardiovascular illnesses such as heart disease and strokes, which kill more people than any other diseases.

The WHO says tobacco kills about six million people a year globally and imposes a huge burden on the world economy. Annual healthcare and lost productivity costs for those made ill from smoking are estimated at around $1 trillion.

The study analysed WHO data from 126 countries – 116 of which are signatories to the FCTC – and tracked and compared the implementation of the five key measures from 2007 to 2014 to look at links between strong policies and smoking rates.

It found that, on average, smoking rates dropped to 22.2 per cent in 2015 from 24.7 a decade earlier. But the trends varied, with rates falling in 90 countries, rising in 24 and remaining steady in 12.

Countries that fully implemented more FCTC measures saw significantly greater reductions in smoking rates, the study found. Overall, each additional measure was linked with a drop in smoking rates of 1.57 percentage points – corresponding to 7.1 per cent fewer smokers in 2015 compared with in 2005.

The study was not a full global analysis, since only 65 per cent of countries had the data needed, but it did include countries from all income levels and regions. The researchers also noted that the lower smoking rates could be influenced by factors other than FCTC policy recommendations.

“The data did not allow a detailed analysis of the impact of individual policies,” said Geoffrey Fong of Waterloo University, who co-led the work.

He called for more studies that are specifically designed to evaluate the impact of all FCTC policies and would “help provide guidance to countries about what policies may offer the greatest benefits”.

Guam raises tobacco age to 21 come 2018

The legal smoking age in Guam will be 21 next year.

http://www.dailymail.co.uk/wires/ap/article-4346104/Guam-raises-tobacco-age-21-come-2018.html

The Pacific Daily News reports (http://bit.ly/2nPFaIb ) that a measure lapsed into law this week raising the legal age to use or purchase tobacco products from 18 to 21 stating Jan. 1, 2018. Lawmakers unanimously passed the measure on March 9 and the governor took no action, meaning the measure automatically became law.

Last year, the Legislature passed a similar bill to raise the legal tobacco age to 21 but Gov. Eddie Calvo vetoed it, saying the bill didn’t give residents the freedom to choose.

According to the American Cancer Society, smoking rates on Guam have declined in recent years to 27.4 percent, but still remain higher than the national average of 17.5 percent.

Oregon Senate approves raising the tobacco use age to 21

The state Senate has approved raising Oregon’s minimum age for tobacco use to 21.

http://ktvl.com/news/local/oregon-senate-approves-raising-the-tobacco-use-age-to-21

The bill approved 19-8 on Thursday now heads to the House. If the proposal is eventually signed by Gov. Kate Brown, Oregon would be the third state to increase the legal age for buying and possessing cigarettes and other tobacco products from 18 to 21.

Hawaii was the first state to increase the age, followed by California. Dozens of cities and local jurisdictions have adopted the policy over the years, including Oregon’s Lane County.

The proposal would reduce Oregon’s tax revenue from tobacco by $1.76 million in the upcoming two-year budget, adding slightly to the state’s projected $1.6 billion budget shortfall.

The losses, however, could be covered from proposals to increase tax rates on tobacco.

Guam raises tobacco age to 21 come 2018

The legal smoking age in Guam will be 21 next year.

http://www.dailyprogress.com/guam-raises-tobacco-age-to-come/article_29ad8ba9-8df0-5ec5-8df2-51f052eee133.html

A measure lapsed into law this week raising the legal age to use or purchase tobacco products from 18 to 21 stating Jan. 1, 2018, The Pacific Daily News reported (http://bit.ly/2nPFaIb ). Lawmakers unanimously passed the measure March 9 and the governor took no action, meaning the measure automatically became law.

Last year, the Legislature passed a similar bill to raise the legal tobacco age to 21 but Gov. Eddie Calvo vetoed it, saying was a “willful intrusion into the personal lives and choices of our citizens.”

Adelup Director of Communications Oyaol Ngirairikl said Calvo maintains his stance that residents should be free to choose, but acknowledges that the majority of senators voted in favor of the smoking-age measure, making it immune to a veto.

“Guam’s youth smoking rate is the highest in the nation,” said Speaker Benjamin Cruz on Thursday. “And at a time when tobacco kills more people than alcohol, car accidents and illicit drugs combined, how then can we ignore the fact that doing nothing would not only have protected Big Tobacco, but condemned future generations of young people to disease and death?”

According to the American Cancer Society, smoking rates on Guam have declined in recent years to 27.4 percent, but still remain higher than the national average of 17.5 percent.

Health care officials who supported the measure to raise the smoking age cited a March 2015 Institute of Medicine report that projected tobacco use in the nation to drop by 12 percent if the legal smoking age was raised to 21.

Is tobacco bill really necessary?

Last week we learned that President Joko “Jokowi” Widodo verbally rejected a proposal from lawmakers for a new tobacco bill that would increase protection of the industry and production of cigarettes. However, he finally gave written agreement for discussion by government and the legislature about the proposed law.

http://www.thejakartapost.com/academia/2017/03/24/is-tobacco-bill-really-necessary.html

Smoking and the tobacco industry have long been big business here with well documented impacts on national, family and individual economies, health and welfare. Today I call on activists concerned for the people of Indonesia to reject the proposed tobacco law, which threatens the health and well-being of our people. It is in conflict with prevailing laws on health and other fields.

We must also raise our voices to point to positive action that the government can take to address some key concerns of the President — an increase in revenues and the welfare of tobacco farmers and workers in the cigarette industry.

A review of some basic facts about smoking and tobacco in Indonesia makes clear the importance of acting promptly.

Among the country’s 255 million people, an estimated 65 percent of adult males are regular smokers, making Indonesia the second-largest cigarette market in Asia after China. Furthermore, in Indonesia the rate of smoking among women has increased rapidly in recent years. This threatens not only the health of these women, but that of their babies and children. Smoking while pregnant increases the risk of miscarriage, low birth weight and respiratory problems in children after birth.

A child growing up with a mother or father or both smoking is at risk in multiple ways. Children’s health may be permanently affected by second-hand smoke in the house. Furthermore children may associate smoking with “being adult” and rush to start smoking themselves leading to early, long-term addiction.

Finally, the households of smokers, particularly low-income families, live with cruel competition for family funds between expenditure on cigarettes and expenditure on good nutrition, clothing, school books and basic medical care. Research shows that it is often the basic needs that lose out — a punishment for the whole family that falls particularly hard on children who are building bones, brains and muscles.

As a pediatrician I would like all parents to be disciplined, caring and active in promoting the best possible life chances for each of their children. Yet science and global experience make clear that the addictive nature of cigarette smoking, peer-group pressure among young people and alluring cigarette advertising makes it easy to start lighting up. Later, smokers find it difficult or impossible to shake the habit.

Therefore I argue not only against the proposed bill.

I also suggest four important actions that could eventually help reduce the threat of smoking to people’s health, thus reducing individual and health expenditure, increase revenue, improve the situation of tobacco farmers and help cigarette factory workers.

First, accede to the Framework Convention on Tobacco Control (FCTC). This global public health treaty aims to reduce tobacco-related causes of ill health and death through cutting legal and illegal supply and demand for tobacco, and protection of health and the environment from tobacco-related damage. Having been adopted by 180 of the 193 UN member states, Indonesia is one of only 13 which is not yet a party to the convention.

Second, increase revenues from tobacco and smoking. The expansion of cigarette production and sales in the proposed bill is presented in terms of expansion of employment opportunities and income for the government.

Yet this increase can be achieved without the bill by increasing the price of a pack of cigarettes (20 sticks), now at US$ 1.40, among the world’s lowest. A significant increase in price will automatically increase revenues from taxes and excises, which benefits the national and regional levels.

Increasing the price would both raise revenue and reduce smoking among the young and the poor -meaning lower treatment costs of tobacco-related diseases.

Third, protect and develop tobacco farmers. Since independence, Indonesia has worked to improve its citizens’ productivity, health services and welfare. There is already a law for the protection and empowerment of farmers (Law No. 19/ 2013). Presidential or other government regulations with special focus could fully meet the needs of tobacco farmers.

Also urgent are special efforts to support farmers wanting to transit out of tobacco farming but without the resources for the startup investment, including training, equipment, seeds etc.

Fourth, protect and attend to the welfare of cigarette factory workers. Similar to farmers, there are laws and regulations that could be used to address their special needs as the industry evolves. And it is clear that even if the cigarette industry expands production in line with the proposed law, it would not expand employment, given the industry’s preference for the speed, efficiency and simplicity of mechanized production.

Layoffs of workers and the shift from hand-rolled cigarettes to mostly mechanized production is already well advanced – 75 percent of kretek (clove-based) cigarettes is now machine rolled. Thus the new law would unlikely provide any significant new employment or support for workers displaced by mechanization.

So is the proposed tobacco bill needed to raise revenues and protect agricultural and factory workers in the industry? No. If we are concerned about the people, their health and well-being, the proposed tobacco bill is clearly unnecessary!

***

The writer is presently leaders’ envoy and board chair for the Asia Pacific Leaders’ Malaria Alliance (APLMA). She served as health minister (2012-2014) and chair of the Global Fund to Fight AIDS, Tuberculosis and Malaria (2013–2015)