Physical health: There is a wide body of evidence
demonstrating a causal link between tobacco and various health issues: lung
cancer and other respiratory conditions, stroke, CVD and CHD (Sim & McKee
2011). That disease incidence/prevalence could be reduced significantly
by the reduction in tobacco consumption, and that there are effective
strategies to do this, puts tobacco control within the scope of public health.
Additionally, that some of these diseases found in non-smokers can be
attributable to passive smoking (Sim & McKee 2011) indicates that this is
not just a personal choice that only affects the individual, but that it has a
deleterious effect on the environment around them and consequently others.
Health
inequalities: Consumption
of tobacco is mechanism that prevents the reduction of health inequalities.
People suffering from higher levels of deprivation both within and without the
higher income countries will likely have poorer knowledge of and/or access to
the health care system within their country, resulting in poorer outcomes form
smoking related diseases than there more affluent counterparts. They are also
likely to smoke more (ASH 2014), increasing their risk of disease, and have
more co-morbidities, reducing the likelihood of a successful outcome. A higher
prevalence of disease within the more deprived groups means more time away from
work and a lowering of their earning potential. This implies that they and
their children will have poorer access to education and therefore are less
likely to escape the cycle of deprivation and health inequalities.
Cost to the health
budget:
Treatment and care of people with diseases, wholly or partially attributable to
tobacco is very expensive. If the prevalence of tobacco attributed disease
where reduced then the money freed up could be put to use elsewhere within the
overall health and care economy.
Freedom of choice: The tobacco
industry may claim that, in a free society, a person has a right to be
unhealthy and a right to choose to smoke. However, there are several arguments
against this position. One, that whilst the individual may have a right to be
unhealthy they also have a duty not to cause undue harm to others. Whilst
eating an entire cheese cake may be an unhealthy thing to do, it does not
directly impact on the health of others around them, whereas someone who does
not smoke can have their health affected by the second hand smoke from other
smokers. Second, there is the economic argument that money spent on the
health care and treatment of those that suffer from tobacco attributable
diseases is money taken away from the health care of those suffering from
diseases not related to an avoidable risk (admittedly this is also true with
eating a whole cheesecake and heart disease risk, but the risk from one
cheesecake is likely small and I will fight anyone to the death who tries to
ban cake). Finally, that tobacco is demonstrably addictive implies that smoking
in not a truly free choice. Also if the health consequences of smoking
are not made clear the potential smoker is unable to make a truly fee and
informed decision.
Jobs and national
revenue:
The tobacco industry claims that it is a growth industry providing employment
to many people, especially in developing countries, and that sales and export
taxes on tobacco crops and products provide governments with money enabling
them to build roads, schools and hospitals. Whist this is undoubtedly true for
some countries, Malawi receives 60% of its export earnings from tobacco, its
impact on the economy is often overstated (Abdullah & Husten 2004). In
developing countries the average earnings from tobacco are 0.16% of GDP (Abdullah
& Husten 2004). Also following a ban on point-of-sale display bans a survey
of found the cost to them to be small, around £300, (ASH 2024) so it is
unlikely that, in most cases, tobacco control measure will have a significant
impact on the overall economy.
Economic: Reducing global
tobacco consumption will result in a reduced demand for tobacco crops. This
could negatively impact those countries who are net exporters of tobacco. These
countries are typically in the developing world and may not have other readily
available natural resources with which to replace this cash crop. Additionally
countries with significant economic power that export tobacco products to less
economically powerful countries, which also rely on other imports, could come
under pressure to relax tobacco import and control laws.
Education/ Social
attitudes: In
some countries little is known about the harmful effects of tobacco. With low
general education levels, communication about the nature risk is difficult. As
a result of a poor understanding of the addictive and harmful nature of
tobacco, the desire for smoking cessation campaigns at individual and
governmental level is likely to be low. Both of these issues will be block to
any public health messages. In addition to these any message seen to come from
and un-trusted government, could be easily ignored by the population. Any
public health message would need to be locally driven in the community.
One
further block to changing social attitudes is the prolific of smoking products.
The tobacco advertising industry aims to associate smoking with
individual rights, independence and modernisation, as well as making smoking
appear aspirational (Abdullah & Husten 2004) This is a powerful message for
public health professional to combat, especially in an environment where little
is known about the dangers of tobacco and pro-tobacco lobbyists are given
plenty of money to ensure that governments are not persuaded to place curbs on
advertising.
Public health
resources: In
developing countries with small public economies, public health programs are
likely to be under resourced, and given the potential for a lack of
understanding of the risks, tobacco control is likely to be a low priority.
Even if funding and political support for tobacco control where made available,
with the poor infrastructure and an inadequately organised national public
health system typically associated with these countries, the delivery of such
interventions could be challenging. For example if the coverage of the
telephone network was far from complete establishing a quit line would be
an inefficient and ineffective use of precious resources (Abdullah & Husten
2004).
Variety of
policies:
Partly due to lack of public health resources, when a developing country does
take action it is often in the form of economic sanctions on tobacco products,
such as higher taxes. Whilst they do have some positive effect (a 10% increase
has been estimated to result in an 8% decrease in consumption, Abdullah &
Husten 2004), they are crude measures and do not attempt to address the
underlying social attitudes towards smoking. Additionally, by increasing the
price to consumers, they can also feed into the advertising industries message
that smoking is aspirational and a luxury. Also in a country with a tradition
of street selling and a sufficiently organised criminal organisation,
increasing tobacco prices, without changing attitudes, can lead to people
buying their cigarettes on the illegal market. It has also been suggested that
the tobacco industry has been complicit in tobacco smuggling (Gilmore
& Martin McKee 2002)
Abdullah, A., & Husten, C. (2004). Promotion of smoking cessation in developing countries: a framework for urgent public health interventions. Thorax, 59(7), 623–630. doi:10.1136/thx.2003.018820
ASH (2014) Smoking Statistics: Who Smokes and How Much http://ash.org.uk/information/facts-and-stats/fact-sheets
ASH (2012) ASH Briefing: Industry claims on point of sale display http://ash.org.uk/information/facts-and-stats/ash-briefings
Gilmore & Martin McKee (2002). Tobacco Control Policy: the European dimension. Clin Med JRCPL, 2, 335
Sim, F. & McKee, M. (2011). 'Issues in Public Health'. Open University Press
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