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6.1 Conclusions

The importance of tobacco use as a global public health problem is indisputable. Moreover, the studies reviewed in this report confirm that cigarette smoking and other tobacco consumption also exact a severe economic toll on developed and developing countries. Tobacco use leads to poor health for those affected, to loss of productivity due to poor health, and to increased consumption of societal resources, especially in the health-care sector.

Tobacco use has a particularly severe economic impact on the developing world. Resources are relatively scarce in developing country contexts, and expenditures on tobacco consumption and tobacco-related illnesses compete in clear and often poignant ways with other social priorities. Moreover, the magnitude of the problem is increasing. Projected global trends show that developing nations are likely to experience by far the largest growth in tobacco consumption, disease and death over the coming two decades. The economic toll associated with this growth is likely to be significant, and can impede country development objectives.

Yet, as this review demonstrates, many tobacco control policies and interventions have been shown to be both effective and cost-effective. To recap, the evidence suggests that macroeconomic interventions such as tobacco taxation policies are an effective means of lowering cigarette consumption due to the inverse relationship between tobacco price and consumption. Considerable scope exists for expanding these policies in developing countries. It should be noted, however, that some evidence suggests that higher tobacco taxes could lead to increased demand for liquor, or to higher consumption of smokeless tobacco.

Another effective measure in reducing the demand for tobacco products is the banning of tobacco advertising. However, compared to taxation strategies, the evidence on the effectiveness of advertising bans as a sole policy instrument is equivocal, and suggests that bans are more effective when implemented as part of a comprehensive tobacco control strategy.

Smoking cessation strategies have also been shown to have a positive impact on reducing tobacco consumption in high-income countries.

Despite these facts, global funding for tobacco control research is inadequate, and overwhelmingly concentrated in high-income countries. The only two major underlying causes of premature death that are increasing dramatically are HIV infection and tobacco use, yet this fact is not reflected in public spending on tobacco control research. A working paper for the 2001 WHO Commission on Macroeconomics and Health reported that for every death due to tobacco use, governments and public agencies spent approximately $50 on tobacco research, versus $3,000 for every HIV death in the same year, based on 1990 estimates. This resulted in a global total for 1990 of $148–164 million for tobacco research, compared to $919–985 million for research into HIV/AIDS (1).

As the results of this review suggest, economic studies have a critical role to play in measuring the real costs of tobacco use to developing countries, and in informing tobacco control policy development. Conclusions are summarized in Box 6.1.

6.2 Recommendations

This section offers recommendations for future policy-oriented research into the economics of tobacco control. As this report and others have shown, the majority of research into the economics of tobacco control has taken place in developed countries (1). This situation should be redressed. Little information exists on the impact of tobacco use in developing countries, despite the fact these countries are expected to experience the largest growth in tobacco consumption, disease, and death over the coming two decades (Chapter 3).

Future research should focus on monitoring the burden of disease in developing countries, to set the stage for comprehensive tobacco control efforts. This information should aid governments in terms of health planning, which is particularly important in view of the time lag between tobacco consumption and disease onset.

Tobacco use has a disproportionate impact on vulnerable population subgroups (Chapter 4). In affluent countries, inverse relationships are found between income and smoking, and between educational level and smoking. These patterns, however, do not always hold in developing countries, where tobacco use has been observed to be increasing in all segments of the overall population. Given the dearth of research on the distribution of smoking prevalence among vulnerable population subgroups in the developing world, future research into this area should be prioritized.

With respect to methodology, studies assessing national tobacco disease burden or examining the economic impact of tobacco use on population subgroups predominantly employed the cost-of-illness (COI) design. Prevalence-based COI studies were more common than incidence-based COI studies, probably largely due to the latter's more demanding data requirements. Incidence-based COI studies, however, are advantageous with respect to evaluating the impact of interventions (e.g., prevention programs) to reduce tobacco use. The disability-adjusted life-year (DALY) approach is designed to help establish resource allocation priorities; yet, to date, only the WHO appears to have employed the DALY-based methodology in tobacco-related studies.

Studies monitoring the burden of disease and its associated economic impact in developing countries should be encouraged. Where feasible, studies should take advantage of existing data sources (Appendix B), and explore alternatives to the prevalence-based COI method.

Studies assessing the effectiveness of interventions to reduce the demand for tobacco (Chapter 5) have been predominantly performed in high-income countries. Part of the problem in designing and implementing tobacco control policies in developing countries concerns a lack of knowledge with respect to the effectiveness of various policies. Moreover, policies effective in high-income settings may need to be tailored to local contexts in low- and middle-income countries. In addition, evidence suggests that academic analyses geared to local needs may increase the likelihood of tobacco control measures being adopted (1). With respect to economic evaluations of prevention and cessation interventions, studies conducted in developing country contexts should be encouraged, as costs and effectiveness are likely to vary across settings. Study methods should be aligned with standard practice. Specifically, the analytical perspective of the studies should use the societal analytical perspective, and future economic evaluations of tobacco cessation strategies should use incremental cost-effectiveness ratios as recommended by health economics literature, rather than average ratios.

Recommendations for future research into the economics of tobacco control are summarized in Box 6.2.

6.3 References

1. Chaloupka, F.J.; Jha, P.; Corrao, M.A.; Costa e Silva, V.; Ross, H.; Czart, C.; Yach, D. The evidence base for reducing mortality from smoking in low and middle income countries. Commission on Macroeconomics and Health Working Paper Series, Paper No. WG5:7, June 2001.

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