By Joy Townsend
Smoking is the cause of roughly one in seven deaths in Europe. The recent study by David Levy et al. shows that half a million people die prematurely each year from smoking in Russia alone – where cigarette prices are particularly low and over 60% of men smoke. By raising taxes from their present rate of 21.5% of retail price to 70% and implementing the range of tobacco control policies agreed in the WHO Framework Convention for Tobacco Control (FCTC), smoking rates could halve and 1.6 million lives could be saved in Russia over the next three decades. Ukraine, with similar high smoking rates and low prices, also has the potential to reduce smoking prevalence by over 50% and smoking deaths by a quarter.
The FCTC is a unique international public health agreement that was adopted in 2003. Many of the 177 countries now signed up to it have implemented an array of changes, although few come close to full implementation. Levy’s far ranging study of five middle- and ten high-income countries across Europe is valuable in modelling predicted changes in smoking and premature death, given each country’s policies, compared with what has been and what could be achieved were the FCTC policies to be fully followed.
The authors predict that these enhanced policies would reduce smoking over time to some 11-16% in most of the countries studied, whereas in others, including Russia, Turkey and Albania, over a quarter of the male population would still smoke after three decades. This disturbing prediction reflects, in particular, the weakness of the FCTC’s price recommendations. Price is a powerful deterrent, and all over the world has been shown to discourage or encourage smoking, according to its level – but 70% of a very low price still represents a very low tax. So it is important for a minimum tax to be expressed in money terms as well as percentages. Another weakness is that tobacco companies continue, often successfully, to lobby governments to weaken tobacco control measures, including taxes.
The substantial minority of smokers shown not to be deterred by the policies may, however, be influenced by other new developments that are not included in the study. The availability of electronic cigarettes, involving the less harmful smoking of nicotine and water vapour, provides the greatest potential for change. Their use is rapidly gaining ground with the endorsement of some public health individuals who think they should be unregulated and freely marketed to maximise availability and harm reduction; if all smokers switched to them it is generally accepted that the harm from cigarettes would be hugely reduced. Others are more cautious. Uncertainty arises about the lack of regulation of product contents, and from the very heavy marketing and advertising already seen, especially directed towards young people. The tobacco industry, a major player, already appears to be attempting to renormalise smoking through their use of advertising. Some countries have banned use in public places, others are considering how to deal with the new products, and undoubtedly, the FCTC, in time, will add its own recommendations. Monitoring, analysis and modelling as in this study are essential to assess the effects of new developments as well as the old familiar ones.
Joy Townsend is Emeritus Professor of Economics, Epidemiology and Health Services Research at The London School of Hygiene and Tropical Medicine