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March 30th, 2017:

Re-energizing tobacco control with evidence-based findings

The accumulated evidence over the past half century on the causal relationship between smoking and harm to health provides us with a robust scientific foundation to inform policy design and action.

Tobacco use is a leading cause of death worldwide, killing close to 6 million people each year. This enormous loss of life and its social and economic impacts undermine development across countries.

While progress has been made in global tobacco control since 2005, when the World Health Organization’s Framework Convention on Tobacco Control (WHO’s FCTC) came into force, renewed effort is needed across low-and middle-income countries, led by national governments, to halt this human-made health scourge once and for all.

In an era, where many question the power of scientific evidence to influence human behavior: whether at the level of individual lifestyle choices, or of public policy, I believe that faith and reason remain the essential guideposts for charting human progress.

The rational case for tobacco control is that it aligns individual self-interest, in terms of preserving health and avoiding suffering, with governments’ economic interests in reducing expenditures, increasing revenue, and maximizing social welfare. Indeed, individual self-preservation, domestic revenue generation, and improvement of overall social well-being is a powerful combination of motivators!

To make this combination work, policy formulation should be informed by a clear understanding of the biological and behavioral mechanisms that lead to the onset of tobacco-related diseases and their adverse health and economic effects. By using country-specific data, we can target policy makers, government officials, and health services personnel, particularly those working at the community level, to raise awareness of the dangers of tobacco for patients, families, and the general population.

The message has to be stark and unapologetic: both active smoking and exposure to secondhand smoke cause disease and kill prematurely. Indeed, accumulated evidence shows that nicotine (a chemical in tobacco): 1) Is a highly addictive stimulant that at high levels produces acute toxicity; 2) activates multiple biological pathways through which smoking increases risk for disease; 3) adversely affects maternal and fetal health during pregnancy, contributing to adverse outcomes such as preterm delivery and stillbirth, as well as congenital malformations (e.g., orofacial clefts); and 4) during fetal development and adolescence has lasting adverse consequences for brain development. It also shows that tar, the resinous, partially combusted particulate matter produced by the burning of tobacco, is toxic. It damages the smoker’s lungs over time. Carbon monoxide, a colorless, odorless gas produced from the incomplete burning of tobacco, accumulates indoors, and reduces the oxygen-carrying capacity of the blood.

We have to hammer home that cigarette smoking is causally linked to diseases of nearly all organs of the body. The evidence is sufficient to conclude that the risk of developing lung cancer from cigarette smoking has actually increased since the 1950s, due to changes in the design and composition of cigarettes. We have to explain that there is evidence for a causal relationship between smoking and several types of cancer, including liver and colorectal cancers, and prostate cancer. Smoking is the dominant cause of chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis; and smoking increases the risk of tuberculosis. We have to show that research continues to identify diseases caused by smoking, including such common diseases as diabetes. Scientists now know that the risk of developing diabetes is 30–40 percent higher for active smokers than nonsmokers.

Crucially, we need to link health arguments with the economic case for tobacco control. That case is powerful, as confirmed by recent studies demonstrating huge smoking-attributable economic costs in the United States and other countries. We can prove that the health benefits of tobacco taxes and other regulatory and control measures far exceed any required increase in taxes and prices, while disproportionately benefiting low-income households, as shown in a recent study in Chile and by results of the 2012 “sin tax reform” in the Philippines. Modeling work, as recently done in countries such as Armenia, Colombia, Lesotho, Moldova, Nigeria, and Ukraine, can inform policy making by reliably quantifying the likely impact of tobacco tax increases on prices, consumption, and domestic revenue mobilization. And related work in Ukraine, shows the estimated positive long-term health and cost-avoided impact of tobacco taxation and other control measures.

As we move into the third decade of the 21st Century, the achievement of smoke-free societies should be a critical marker of sustainable development. Globally, Finland, is paving the way. It has become the first country to set the goal of making itself tobacco-free by 2040. But to realize that vision, saving our children and their children from tobacco addiction, disease, and early death, we have to move from declaration of good intentions to committed, measurable, and sustained action over the medium term that is informed by quantifiable public health and economic evidence.