Tobacco Control
W hy is reducing use of tob acco
a priority?
Tob acco is becoming one of the single biggest causes
of death worldwide. By 2 0 3 0 it is expected to kill 1 0
million people per ye ar; half a ged 3 5-6 9. The
epidemic is increasingly affecting developing
countries, where most of the world’s smokers (8 2% or
9 5 0 million) live. Close to half of all men in low-
income countries smoke d aily and this has been
incre asing. For example, smoking prevalence among
Chinese men incre ased from 4 0% in the 1 9 5 0s to
6 3% in 1 9 9 6 (Chinese Aca demy of Preventive
Medicine 1 9 9 6). Women’s smoking rates are also
incre asing fast. By 2 0 3 0, developing countries will
account for 7 0% of all tob acco de aths. Many deaths
and much disease could be prevented by reducing
smoking prevalence.
Smoking and poverty. Episodes of ill he alth, the costs
of he alth care, and premature de ath are frequently
cited by poor people as their gravest concerns, and
as the precipitating cause that pushes families into
poverty. Smoking prevalence tends to be higher
among men with less education and lower incomes,
so they be ar a gre ater he alth risk. Also, the
opportunity cost of money spent on cig arettes is
obviously higher for people living on low incomes –
money spent on tob acco products could help feed
families. Tob acco is often a significant p art of family
expenditure: low income households with at le ast one
smoker in Bulg aria spent 1 0.4% of their total income
on tob acco products in 1 9 9 5; urb an households in
Tibet spent 5.5% of their monthly disposa ble income
on tob acco products in 1 9 9 2; and in China , smokers
in 2,7 1 6 households in Minhang district spent 1 7%
of household income on cig arettes ( G ong et al, JA M A
1 9 9 5, 2 7 4:1 2 3 2-4).
The harm from second-hand smoke to others,
especially unborn and young children, further justifies
intervening to reduce tob acco use. 7 1 0 million
children live in households where someone smokes
(Lope z , W H O , 1 9 9 9). M any smokers do not know
their risks, begin smoking at very young a ges and
most later regret ever starting and would like to quit.
at a glance
For example, 6 1% of Vietnamese smokers surveyed
in 1 9 9 5 said they w anted to quit, and 4 4% ha d tried
to quit (Jenkins et al, 1 9 9 7). In China and in other
developing countries, the avera ge a ge at which
people begin to smoke is falling from e arly 2 0s to
teens. N icotine is highly a ddictive, so it is important
to discourage smoking initiation, especially among
young people. Because many of the expected de aths
from tob acco use will be among the 1.1 billion
people who now smoke, persua ding and helping
people to quit is key to reducing dise ase and de ath
from tob acco use.
The Framework C onvention on
Tob acco C ontrol (F CTC)
The F CTC w as a dopted by W H O member countries
in M ay 2 0 0 3. It will commit all countries that ratify it
to: eliminate all tob acco a dvertising, promotion and
sponsorship within 5 ye ars (with a narrow exception
for those nations whose constitutions prohibit a
complete b an); require w arning la bels occupying at
le ast 3 0% of the are a of cig arette p acks (and
suggests 5 0% or more); prohibit misle a ding tob acco
product descriptors such as “light” and “mild”; and
protect nonsmokers from tob acco smoke in public
places. The F CTC also urges strict regulation of
tob acco product contents; higher tob acco taxes,
glob al coordination to fight tob acco smuggling, and
promotion of tob acco prevention, cessation and
rese arch programs.
N ational tob acco control efforts are usually led by
the Ministry of He alth, associations of physicians and
other he alth groups, or dedicated anti-smoking
groups. N G O s, women’s groups, youth groups,
la wyers, economists and environmentalists play key
roles in some countries. Ministries of Finance,
Economic Planning and Taxation are important,
because higher tob acco taxes are the single most
effective w ay to reduce use. O ther stakeholders
include: Ministries of A griculture and farmers,
Ministries of La bor and Industry, employee groups,
Ministries of Education, media , retailers, and sports
groups (sponsorship).
June 2003
C ost Effective Interventions to reduce de ath and dise ase caused by tob acco use
Measures to reduce demand for tobacco products are highly cost effective – very high on the list of public health
“best buys”

Objective: Reduce tobacco use, to reduce death and disease caused by tobacco use.

Interventions Beneficiaries / Target Groups Process Indicators

Higher taxes on cig arettes and other smokers ✓ price of cig arettes / bidis etc (a djust for
tob acco products inflation)
potential smokers (especially youth)
✓ tax as % of final sales price

Non-price measures
Bans / restrictions on smoking in public non-smokers protected from second-hand ✓ smoke-free public sp aces and places
and work places: schools, he alth smoke
facilities, public transport, restaurants,
cinemas etc.

C omprehensive bans on advertising and smokers and potential smokers ✓ la ws, regulations, extent to which
promotion of all tob acco products, logos (especially youth) respected / enforced
and brand names1
societal attitudes to smoking

Better consumer information: counter- smokers and potential smokers ✓ knowledge of he alth risks, attitudes to
a dvertising, media covera ge, rese arch smoking
findings societal attitudes to smoking

Large, direct warning labels on smokers ✓ % of box surface covered by la bel,

cig arette boxes and other tob acco messa ge, color / font specifications
products
Help for smokers who wish to quit, smokers ✓ number of ex-smokers
including incre ased access to N icotine
Replacement ( N RT) and other cessation
thera pies

Impact / surveillance Indicators for tobacco use (from survey data):

adult smoking prevalence: % of people 1 5 and older who use any tob acco product at le ast once a d ay (d aily / regular smoker)
or occasionally, % who have ever smoked

intensity: avera ge number of cig arettes (and other tob acco products) smoked / used d aily

quit behavior: % who used to smoke, but currently do not smoke at all

youth use: % of young people who currently use any tob acco product (defined as having used a tob acco product on one or
more d ays during the p ast 3 0 d ays),

initiation age: a ge at which current and ex-smokers first started to smoke at le ast one cig arette a d ay

N ote: A G lob al Youth Tob acco Survey is being implemented in many countries with support from W H O and C D C . See:
http: / / tob acco.int / en / youth / gyts / html (on the W H O website) or http: / / www.cdc.gov / tob acco / rese arch_d ata / youth / gytsfact-
sheets.pdf (C D C website)

1
If full b ans are impossible, strong restrictions, and significant counter-a dvertising should be pursued.
The evidence shows:
(useful information)
■ The best results are achieved when a comprehen-
sive set of measures to reduce the use of tobacco
are implemented together. M any countries have
succeeded in reducing smoking prevalence
dramatically, and consequently reduced cancers,
he art dise ase and other circulatory dise ases,
respiratory dise ases, and low birth weight
incidence.
■ Price increases are the most effective and cost-
effective deterrent – especially for young people
and others with low incomes, who must, of
necessity, be highly price responsive. A price rise
of 1 0% decre ases consumption by a bout 8% in
low- and middle-income countries. Higher taxes
will generate a dditional government revenue.
■ In almost all countries, as people switch expendi-
tures from tob acco to other goods, there will not
be net job losses. As demand for tob acco products
falls, jobs lost in tob acco farming, manufacturing
and distribution, are offset by new jobs cre ated in
other sectors in response to changed expenditure
p atterns. Some countries (M ala wi and Zimb a bwe)
and are as within other countries whose economies
depend he avily on tob acco, may need help in
a djusting to new consumption p atterns.
■ Erosion in glob al demand for tob acco will
prob a bly be slow and gra dual, in the face of
growing population numbers, rising incomes,
social norms, a ddiction, and a dvertising and
promotion of tob acco use.
■ Most measures to reduce supply are ineffective
(prohibition, youth access restrictions, crop
substitution efforts and tra de restrictions). Control
of smuggling is the exception, and is the key
supply-side measure to pursue.
■ W ill poor smokers be hurt by tob acco product
price incre ases? Those who decide to quit or cut
b ack their use of tob acco products will g ain he alth
and income. People who do not reduce or quit
smoking in the face of price incre ases will p ay
more. If this is an important issue, compensating
tax / price cuts in other products (eg b asic foods)
might be considered, and / or targeted cessation
programs.
■ Many smokers want to quit, and could use help.
Most people who quit do so without help, but
nicotine a ddiction makes quitting very hard. Q uit
rates can be substantially incre ased through
a dvice from he alth care providers, telephone “quit-
lines”, formal and informal support-groups, and
cessation thera pies including nicotine-replacement
( N RT). O ver-the-counter (non-prescription) sales
improve access to N RT. There are many potential
opportunities for cessation a dvice and support:
e.g. as p art of TB tre atment.
■ What works for youth? The most effective tool to
reduce / deter use of tob acco products by young
people: price increases. Bans on tob acco product
sales to young people are difficult and costly to
enforce. Policies should be tailored to affect the
usual sources from which young people get their
cig arettes or other tob acco products. For example,
some countries have reduced youth access to
tob acco products (especially cig arettes) by
b anning sales through vending machines. Free
distribution of tobacco products and promotional
products (T-shirts, school note books etc) should be
strictly banned.
■ Health warnings on cig arette p acka ges should be
large (cover at le ast 3 0% of the surface are a and
prefera bly 5 0% or more), cle ar (e.g., black on
white), in local langua ges, and have a set of
specific required messa ges that change
periodically. Information on the a dverse he alth
imp act of tob acco use and the benefits of quitting
should be widely disseminated.
■ The tob acco industry argues that advertising and
promotion affects market share and not overall
prevalence levels, but countries that have
implemented comprehensive b ans on all
a dvertising and promotion have reduced tob acco
use much more quickly and to lower levels than
other countries. Partial b ans are not effective – if
only a p artial b an is politically fe asible, then there
is a very strong case for mand ating counter-
a dvertising (e.g the Fairness Doctrine in the USA ,
and in South Africa where the state ra dio
corporation g ave free air time every d ay for anti-
smoking messa ges, while continuing to benefit
 from substantial cig arette a dvertising revenues.
■ Efforts to reduce smoking face formid a ble
obstacles: nicotine a ddiction; social pressures;
a ggressive cig arette marketing and promotion;
other pressing he alth problems; overestimates of
the economic importance of tob acco; and the
vested interests of those who live and profit by
Resources
People in the World Bank and IMF
■ HD N HE’s tob acco te am: Joy de Beyer, Ayd a
Yurekli, Sa brina Huffman. M aureen La w is the
H N P Sector Board member responsible for
tob acco. Email: jdebeyer@worldb ank.org,
ayurekli@worldb ank.org
■ IMF fiscal dep artment (Peter Heller and Emil
Sunley, for help in assessing the potential for
tob acco tax incre ases and discussion with Ministry
of Finance and other tax authorities.
Documents and data
■ “ Curbing the Epidemic: G overnments and the
Economics of Tob acco C ontrol”, World Bank,
1 9 9 9. Development in Practice Series. O n line at:
http: / / worldb ank.org / tob acco, or hard copy from
the Infoshop, or HD N HE’s tob acco te am. Short,
re a d a ble and cle ar. Analyz es and summariz es the
rese arch and key economic and social issues
relating to tob acco control. Also availa ble in 1 8
other langua ges, and a “key messa ges” summary
brochure, and powerpoint slides are availa ble.
■ “Tob acco C ontrol in Developing C ountries”, Jha
and Chaloupka , O UP for the World Bank and
W H O , 2 0 0 0. Detailed b ackground p a pers for
“ Curbing the Epidemic”. Availa ble online at
www.worldb ank.org / tob acco
Expanded versions of the “at a glance” series, with e-linkages to resources and more information, are
available on the World Bank Health-Nutrition-Population web site: www.worldbank.org / hnp
cig arette sales. But there are many good success
stories that could be replicated with political will,
and broa d support. Modest action could save
millions of lives and avert much disease, including
among poor people, without long-term harm to
economies.
■ http: / / worldb ank.org / tob acco for economics of
tob acco notes on selected countries, country-
specific d ata , slide presentations, useful websites
(see especially W H O / TFI and C D C)
■ Details of tob acco control activities in he alth
projects funded by World Bank from Sa brina
Huffman, HD N HE, World Bank. Email:
shuffman@worldb ank.org
■ A good d ata b ase of tob acco prevalence studies
and other country-specific d ata is being developed
by W H O / C D C / World Bank / American C ancer
Society – availa ble in July 2 0 0 1 at
http: / / worldb ank.org / tob acco also at C D C and
W H O / TFI websites
■ At a glance fact sheets on strong re asons to make
smoke-free workplaces and how to go a bout doing
it, and on tob acco p ack information are availa ble
online at www.worldb ank.org / phata glance and
www.worldb ank.org / tob acco
“How to” toolkit for analysis of economic issues
Explains in detail how to analyz e tob acco
price / consumption relationship, tax rates and
revenues, options for setting and a dministering
tob acco taxes, smuggling, employment, and imp act
on the poor. Describes d ata needs and sources,
analytic model specification, and interpretation of
estimation results. Availa ble (in draft) from World
Bank tob acco te am, and at
www: / / worldb ank.org / tob acco