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"Very rarely do we have the ability to predict an epidemic so far in the future and also have the knowledge to prevent it."

11th World Conference on Tobacco or Health (9)

1.1 The Tobacco Epidemic

Tobacco use is now widely acknowledged to be the single most important preventable cause of health problems worldwide (1). Despite this consensus, approximately 1.1 billion people smoke worldwide, and over 4 million people currently die of tobacco use each year (1). Between 2025 and 2030, the total number of smokers is expected to reach about 1.6 billion out of a global population of 8.5 billion, with approximately 10 million smokers dying annually (2). Current worldwide smoking patterns suggest that 500 million people alive today will eventually die of tobacco use (2). About 100 million of these deaths will occur among Chinese men alone (2).

Once largely a problem in developed countries, the tobacco epidemic has become a growing concern in many developing countries as well. In high-income countries, the trend in overall numbers of smokers has shown a general decline over the past three decades. In low and middle-income countries, however, the overall number of smokers is increasing, and these now account for more than 80% of today's total worldwide smoking population (2). The tobacco epidemic has therefore expanded from its original locus, high-income countries, to low-income regions.

A 1988 WHO press release reported that while tobacco markets are decreasing in Western, industrialized countries at the rate of 1% per year, tobacco consumption is increasing in developing countries at an average rate of 2% per year, outstripping global population growth (3). Of the estimated 10 million annual tobacco-related deaths expected by 2030, 7 million will occur in developing countries (4).

People in developing countries now consume approximately one-third to just over one-half of the world's tobacco (1). To illustrate this, between 1970 and 1990, for every tonne of tobacco that Canadian adults gave up, populations in the low and middle-income countries of Africa, Latin America, Asia and the Middle East consumed approximately 20 additional tonnes (5). Unfortunately, legislative controls and other measures used to limit the use of tobacco either do not exist or function poorly in most developing countries (3).

The increase in cigarette smoking in developing countries is largely due to the shift in attention of transnational tobacco companies from the developed world, where they face a powerful antismoking climate, to the markets in the developing world. In low and middle-income countries, tobacco companies are successfully targeting their advertising at women, the young, and the business and professional classes.

China is the largest producer and consumer of cigarettes in the world (3). Over half the global increase in tobacco use between 1976 and 1986 took place in China, where 61% of males over 15 years of age and almost 75% of males aged 45–64 are smokers (7). Overall, China has about 300 million smokers, and has been labeled the prize of the tobacco market. According to one study, male lung cancer mortality in China is expected to rise to 900,000 annual deaths in 2025, from 30,000 deaths in 1975 (7).

Bangladesh is another notable case. In the past 10 to 15 years, cigarette consumption has more than doubled in that country, and over 100,000 acres of land that could produce food are planted with tobacco instead (8). Tobacco is a direct competitor for land with transplanted aman, the major rice crop, and with wheat. Lung cancer is already the third most common cancer among males, and annual deaths from this cause are expected to increase by 1,200 within 15 years (8). A more important health risk, however, may be the reduction in nutritional status of young children that results from expenditure on tobacco products in households whose income for food purchases is already marginal. Smoking only five cigarettes a day in a poor household in Bangladesh could lead to a monthly dietary deficit of 8,000 calories (8), which could be fatal for already malnourished children.

Given the perilous situation concerning tobacco use in the developing world, the time is right for researchers and policy-makers to focus on the problem before the dire predictions described above become matters of fact.

1.2 Tobacco Control Efforts

Tobacco use is a global problem that requires countries to cooperate in strong international action even as they tailor their tobacco control efforts to their own unique circumstances. In October 2000, representatives from 150 countries convened in Geneva, Switzerland, to begin negotiating the first international convention to address a health issue in the 50-year history of the WHO. Due to be completed by 2003, this agreement is known as the Framework Convention on Tobacco Control (10).

Developing countries are already overwhelmed by problems of malnutrition and endemic infectious diseases, and these problems are exacerbated by the absence of adequate health services (6). These countries can ill afford the increase in mortality caused by the tobacco epidemic, whether measured in terms of loss of human health, or in terms of economic costs (e.g., use of medical and health-care services, lost productivity, fires, or the use of land to grow tobacco) (4).

Because the tobacco epidemic is more recent in developing countries, the adverse health consequences are not yet as evident as they are in developed countries (4). Basic epidemiological information is lacking in many developing countries. Of countries that do have such data, most of the reliable or countrywide surveys that were used to extract the data were initiated too late to be useful at this time. As a result, there is insufficient information on trends in the diseases and mortality caused by smoking (4, 6). Public knowledge of tobacco hazards is also often lacking or absent (6).

The problem is compounded by the fact that life expectancy at birth in developing countries is 63 years, 12 years shorter than in developed countries (4). Tobacco-related health problems in developing countries have hitherto been masked by this shorter life expectancy, as some smokers die from other causes (4). In some poor countries, however, the epidemic of smoking-related diseases already rivals infectious disease and malnutrition as a priority public health problem (1). As life expectancy increases, the tobacco toll will become even more evident (4). According to the WHO, "smoking diseases will appear in developing countries before communicable diseases and malnutrition have been controlled, and thus the gap between wealthy and poor countries will widen further" (3). It is therefore imperative that preventive action be taken to combat the ill effects of tobacco use.

The governments of many developing countries underestimate the direct and indirect costs of tobacco use, while they tend to overestimate the importance of tobacco for their national economies. Consequently, many governments have not yet implemented tobacco control policies to discourage tobacco use. An enhanced understanding of the economic dimensions of the tobacco epidemic is required to advance effective tobacco control policies in developing countries. Data concerning the health and economic consequences of the epidemic are also needed, as well as information on how these health sequelae and costs are distributed among individuals, households, communities, and society at large. Costs to society at large must be further distinguished from those of the public health-care system, as the proportion of costs borne by the latter varies from country to country, depending on political, economic, social, and cultural factors. Standardized economic evaluation methods are needed to help governments and researchers measure the real costs of tobacco use to their societies, thus paving the road to informed tobacco control policies.

RITC produced this report in an attempt to lay the groundwork for future comparative and conclusive research in the field of tobacco-related economic evaluation, with a focus on developing countries. This report reviews and synthesizes the literature on tobacco-related economic evaluation, and documents the methodologies used to measure the costs of tobacco use to health-care systems and societies. It is directed at a general audience of tobacco control researchers and policy-makers, especially in developing countries, and researchers familiar with economic evaluation methods but unfamiliar with the relevance of these methods to the study of the tobacco epidemic.

1.3 Aims of Report

The aims of this report are as follows:

• To provide an overview of the role and methods of economic studies in tobacco control policy development, and to assess the advantages and disadvantages of each methodology (Chapter 2);
  
  
• To provide an analysis of the most recent and important findings concerning the impact of tobacco use on individuals and health-care systems in various societies, particularly (as information permits) in developing countries (Chapter 3);
  
  
• To provide an analysis of the findings and methodologies of studies examining the impact of tobacco use in specific population subgroups (Chapter 4);
  
  
• To provide an analysis of economic assessments of interventions to reduce the demand for tobacco (Chapter 5); and
  
  
• To set the stage for future economic research in the area of tobacco control policy by (a) identifying gaps in existing research and opportunities for effective future contributions, and (b) identifying the relevant information sources for analysis of the economic impact of tobacco use, and reflecting on the availability and utility of each (Conclusions, Appendices).

1.4 Methodology of Report

The MEDLINE, HealthSTAR, EconLit, and Cochrane Database of Systematic Reviews databases were searched to identify published articles related to the economics of tobacco use. Three categories of words were formed to generate a comprehensive search of articles related to tobacco (keywords: "tobacco", "cigarette", "smoking", "smoker"), economics ("cost", "expenditures", "economic evaluation", "economic impact"), and developing countries ("developing countries", "developing world", "third world"). The three groupings were then combined to identify articles related to the economics of tobacco and, more specifically, articles dealing with this topic in developing countries. The scope of each database and the dates covered in the search are presented in Table 1, and a detailed description of the contents of each database is given in Appendix A.

The literature identified throughout this methodology is presented in the following chapters.

All currencies in this report have been converted into U.S. (United States) dollars. For any study reporting results in a currency other than U.S. dollars, a conversion was made using exchange rates in effect on December 31 of the year in question for the study. Exchange rates were obtained from the U.S. Federal Reserve Bank of St. Louis ("Exchange Rates, Balance of Payments and Trade Data," at www.stls.frb.org/fred/data/exchange.html#discontinued, accessed June 25, 2002).

Table 1.1 Databases and Dates Covered in the Literature Review.
Database	Scope	Dates Covered
MEDLINE	Biomedical literature	1966–2001
HealthSTAR	Health services, technology, administration, and research	1975–2000
EconLit	International economic journals	1969–2001
Cochrane Database of Systematic Reviews	Systematic reviews of the effects of health care	2001

1.5 References

1. Stebbins, K.R. Transnational tobacco companies and health in underdeveloped countries: Recommendations for avoiding a smoking epidemic. Social Science in Medicine 1990; 30:227–235.

2. The World Bank. Curbing the Epidemic: Governments and the Economics of Tobacco Control. Washington, DC: World Bank, 1999.

3. Mackay, J. Battlefield for the tobacco war. Journal of the American Medical Association 1989; 261:28–29.

4. Mackay, J.L. The fight against tobacco in developing countries. Tubercle and Lung Disease 1994; 75:8–24.

5. Phillips, A.; de Savingny, D.; Law, M.M. As Canadians butt out, the developing world lights up. Canadian Medical Association Journal 1995; 153:1111–1114.

6. Al Arah, M.; Ball, K. Tobacco: A major challenge for the developing world. Tropical Doctor 1992; 22:1–2.

7. Richmond, R. Ethical dilemmas in providing tobacco to developing countries: The case of China. Addiction 1997; 92:1137–1141.

8. Cohen, N. Smoking, health, and survival: Prospects in Bangladesh. Lancet 1981; 8229:1090–1093.

9. Saloojee, Y. Regional summary for the African region. In Corrao, M.A.; Guindon, G.E.; Sharma, N.; Shokoohi, D.F., ed., Tobacco Country Profiles. Atlanta, GA: American Cancer Society, 2000: 23–26.

10. Editorial. Why we need an international agreement on tobacco control. American Journal of Public Health 2001; 9:191–193.

Document(s) 2 of 9