The tobacco epidemic is one of the biggest public health threats the world has ever faced, killing more than 7 million people each year through direct exposure, secondhand smoke and smokeless tobacco. Tobacco is the second leading mortality risk factor, contributing to many noncommunicable diseases, including cancer, cardiovascular disease and lung disease. Many of these deaths are considered premature, happening before people turn 70. About 80 percent of the world’s 1.1 billion smokers live in low- and middle-income countries (LMICs). Worldwide, health care expenditures to treat diseases and injuries caused by tobacco totaled nearly 6 percent of global health expenditures. Further, tobacco use can reduce productivity by permanently or temporarily removing individuals from the work force due to poor health.
To combat the tobacco epidemic, the World Health Organization (WHO) created the Framework Convention on Tobacco Control (FCTC), which was adopted in February 2005. The FCTC is the first global public health treaty and aims to tackle causes of the tobacco epidemic, including trade liberalization and direct foreign investment; tobacco advertising, promotion and sponsorship beyond national borders; and the illicit trade in tobacco products. Currently, there are 181 Parties to the WHO FCTC, covering more than 90 percent of the world population.
While there have been remarkable achievements following the adoption of the FCTC, many countries are still working to implement tobacco control. The FCTC 2030 project is meant to strengthen tobacco control in low- and middle-income countries by promoting and supporting governments to accelerate the implementation of FCTC measures. RTI contracted with the United Nations Development Programme to prepare the case for investing in tobacco control in 15 countries that were selected to receive direct support under the FCTC 2030 project. RTI analyzes the health and economic costs of tobacco use in each country through smoking, secondhand smoke exposure and smokeless tobacco use, as well as the potential gains from scaling up implementation of a set of key tobacco demand-reduction policies recommended by the FCTC. The investment cases provide policymakers with evidence needed to inform decisions around implementing tobacco control measures. Focusing on the economic rationale for tobacco control, investment cases aim to connect with a broad range of government policy makers by demonstrating that tobacco control can be a win-win for development.
The Architecture of a Country-Specific Investment Case
Each FCTC investment case consists of two components. The first component—assessing the current health and economic burden of tobacco use in a given country—involves estimating tobacco-attributable mortality and morbidity as well as the direct and indirect economic costs of tobacco use. The second component examines the impact that implementing new tobacco control policies—or intensifying existing ones—can have on reducing these health and economic costs. Policy measures include:
- Implementing and enforcing bans on smoking in all public places to protect people from tobacco smoke;
- Implementing and enforcing bans on all forms of tobacco advertising, sponsorship and promotion;
- Increasing tobacco taxation to reduce the affordability of tobacco products;
- Mandating large graphic labels to warn about the dangers of tobacco smoke;
- Mandating plain packaging of tobacco products; and,
- Promoting public awareness about the harms of tobacco use via national mass-media information campaigns.
To estimate the impact of implementing tobacco control policies and interventions over the short- and medium-term, the investment cases project health and economic outcomes over a 15-year period for two scenarios. In the status quo scenario, current policy efforts are ‘frozen,’ meaning that, through the year 2033 (end of the analysis), no change occurs from the tobacco control provisions that are currently in place. In the intervention scenario, the country implements new tobacco measures, or intensifies existing ones, to reduce the prevalence of smoking. The difference in health and economic outcomes between the status quo and intervention scenarios represents the gains that the country can achieve by taking targeted actions to reduce tobacco use.
Key Messages from Tobacco Investment Cases
The first FCTC Investment case was piloted in 2017 in the country of Georgia, with preliminary findings presented in April 2017 and final results delivered and presented to members of the Georgian Ministries of Labor and Health in February 2018. Since the completion of the pilot investment case, RTI has completed and presented four additional investment cases to high-level policy makers in El Salvador, Myanmar, Zambia and Nepal.
Within these five countries, tobacco-attributable illnesses kill anywhere from 4 to 22 percent of the population, with the highest percentage found in Georgia. Large portions of tobacco-related deaths occur before the age of 70. For example, in Zambia, premature deaths represent 60 percent of the tobacco-related deaths in the country.
Alongside the cost to health, tobacco imposes a substantial economic burden. The investment cases calculate health care costs due to tobacco use, and indirect costs to economies caused by tobacco’s impact on the labor force. When individuals die prematurely, the labor output that they would have produced in their remaining years is lost. In addition, individuals with poor health are more likely to miss days of work (absenteeism) or, when they are at work, to operate at a reduced capacity (presenteeism, smoking breaks).
To date, the results from the investment cases demonstrate that the total economic cost associated with tobacco use is the equivalent of 1 to 3.5 percent of total GDP each year, with the highest percentage loss occurring in Myanmar. Most of these costs, anywhere from 56 to 95 percent, are due to the indirect costs of tobacco use.
Implementation of tobacco control
The investment cases demonstrate the potential to achieve significant health and economic gains by implementing and enforcing key tobacco demand reduction policy measures prioritized by the FCTC.
Implementing the full package of measures in each of the five countries would save nearly half a million lives and avert more than US$9 billion in economic losses by 2033.
Despite the known health impact of tobacco, countries have not yet implemented the full package of tobacco demand reduction policies for many reasons, including pressure from the tobacco industry, fears of policy cost, possible disruption of the economy and unpopularity of policies among constituents.
However, the investment cases demonstrate the efficiency of implementing the measures by quantifying the expected return on investment (ROI). The ROI answers the following question: for every dollar that a government invests in tobacco control measures, how many dollars can it expect to receive in return in economic benefits?
Within the five countries, the ROI for the package of interventions ranges from $40 to $225 returned for every $1 spent.
How tailoring each case to a country is beneficial
Political pressures and tobacco industry influence are not the only barriers to full implementation of tobacco control measures in developing countries. Other barriers include concerns about the impact on tobacco farmer livelihoods and the impact of tobacco taxation on the poor. Additionally, countries are interested in the role of other issues in tobacco control such as second-hand smoke and tobacco products other than cigarettes. We analyzed qualitative and quantitative evidence from these countries to help governments make informed decisions about their tobacco policy enforcement and negate concerns they have with tobacco enforcement. For example in Myanmar, tobacco control has actually been found to be the most beneficial for the poorest populations as they are more likely to quit smoking with increased tobacco taxation. The reduction in smoking prevalence among the poorest leads to a subsequent decrease in tobacco-related health problems and medical costs.
The FCTC Investment Case in Action
The FCTC investment cases have been used by policymakers, government officials and Ministries of Health and Finance to promote stronger tobacco legislation in their countries in accordance with the FCTC framework.
- In Georgia, the pilot investment case presented in 2017 was used by Georgian policymakers to pass landmark tobacco legislation that includes prohibition of smoking in enclosed public spaces, workplaces and public vehicles; bans advertising, sponsorship and promotion of tobacco products; and enforcement of plain packaging and health warnings on tobacco products. The launch of the full investment case in Tbilisi, Georgia in February 2018 was used to promote awareness and advocacy among the public for the new tobacco taxation through media coverage.
- Zambia is using the results of its investment case to promote the passage of the “Tobacco Products and Nicotine Products Bill,” which has been in draft since June 2018 and will come up for formal consideration in summer 2019. Results from the investment case were presented in February 2019, generating numerous media articles.
- Investment cases results were presented and widely disseminated to government officials in El Salvador, Myanmar and Nepal and will be used to advocate for stronger tobacco control in those countries, including revising the tax structure for tobacco in Nepal and increasing tobacco taxes in Myanmar.
Investment cases continue to be used for tobacco control advocacy by governments even today. Georgia continues to utilize the investment case results to advocate for tobacco control through events such as the FCTC Conference of Parties in October 2018, and its parliamentarians’ forum on tobacco control in April 2019 in collaboration with the FCTC 2030 project. El Salvador is continuing its study of the impacts of tobacco in its country through FOSALUD (one of the partners for the investment cases) and the International Union Against Tuberculosis and Lung Disease.
In addition to the promotion of stronger tobacco legislation among government officials, the findings from the investment cases are used for advocacy for tobacco control among the public. The El Salvador investment case results were presented to more than 100 members of civil society and at a press conference with local media. The results were further shared with the public through local TV, print, radio and social media. In Myanmar, the Minister of Health and Sports gave an address to government agencies, researchers and the public stating the tremendous importance that the investment case report will have for informing tobacco control policies and efforts.
Encouraging Countries to Use the FCTC Framework
In addition to the five completed investment cases, work is ongoing for 10 additional countries supported by the FCTC 2030 project. Results of these investment cases will be disseminated to countries throughout 2019. While we are only one-third of the way through presentation of the results of our investment cases to individual countries and policy makers, the demand for this work by countries is high. There is significant interest in the results of the investment cases by Ministries of Health to inform their policy actions and efforts.
Presenting a case for increasing tobacco taxes, enforcing smoking bans, and altering cigarette packaging is one thing, but convincing governments to buy into a tobacco-control plan is quite another. “The tobacco industry has a lot of power,” says Nathan Mann, the RTI research economist supervising the FCTC investment cases. “One African country passed a tobacco-control policy, and the industry took them to World Trade Court—they essentially said, ‘we have more money than your entire country.’”
By legislating and funding these important measures, these countries can set the stage for curbing the global tobacco epidemic. However, success is not guaranteed, as the impact from the FCTC measures depends on concerted and coordinated efforts from multiple sectors of government, as well as cooperation from the private sector and, of course, a population sufficiently willing and incentivized to change its behavior vis-à-vis tobacco use.