Wednesday, 24 December 2014

Yawn, smoking, here we go again...

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

ASH (2012) ASH Briefing: Industry claims on point of sale display

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

No comments:

Post a Comment