This is a writeup of a shallow investigation, a brief look at an area that we use to decide how to prioritize further research.
In a nutshell
- What is the problem? The World Health Organization (WHO) estimates that tobacco is the largest cause of preventable death in the world, responsible for almost 6 million deaths each year, with nearly 80% of the burden falling on low- and middle- income countries.
- What are possible interventions? There are a variety of policies, including increased taxes on tobacco, that the WHO reports reduce tobacco use. A philanthropist could undertake any of a variety of strategies to attempt to ensure passage and enforcement of such policies. We do not have a good sense of the likely returns to the different potential strategies.
- Who else is working on it? The Bloomberg and Gates foundations each devote significant funding to tobacco control efforts, perhaps totaling about $80 million per year, working with an international coalition of partners. We do not have a systematic accounting of funding from other sources, but overall expect that funding for tobacco control efforts is about an order of magnitude less than funding for malaria or tuberculosis on a per-person-affected basis.
1. What is the problem?
The World Health Organization estimates that tobacco is the largest cause of preventable death in the world, responsible for nearly 6 million deaths each year, with nearly 80% of the burden falling on low- and middle- income countries.1 Most of these deaths are the result of tobacco use (primarily but not exclusively smoking), but about 600,000 a year are reportedly due to second-hand smoke.2 If no action is taken, the number of annual tobacco deaths is projected to rise to more than 8 million by 2030.3
The prevalence of smoking varies, amongst other dimensions, by gender and country income:4
- Amongst adult men, the prevalence of smoking is higher in middle- and high-income countries (34% and 30%, respectively) than in low-income countries (21%).
- Amongst adult women, the prevalence of smoking is higher in high-income countries (19%) than low- and middle-income countries (3% and 5%, respectively).
2. What are possible interventions?
The World Health Organization has developed MPOWER, a package of six policy interventions that are believed to reduce tobacco use.5 The MPOWER package of policies includes:6
- Monitoring tobacco use and prevention policies
- Protecting people from tobacco use
- Offering help to quit tobacco use
- Warning about the dangers of tobacco
- Enforcing bans on tobacco advertising, promotion and sponsorship
- Raising taxes on tobacco
To support the adoption and enforcement of these policies around the world, a philanthropist could support any of a variety of activities:7
- Improved monitoring of tobacco usage globally
- Training for journalists to report on tobacco as a public health issue and to push for enforcement of adopted policies
- Mass media advertising to make people more aware of the dangers of tobacco and to mobilize support for a particular policy agenda
- Targeted outreach to decision-makers in governments
- Grassroots activism aimed at raising the level of attention devoted to tobacco use
- Programs to support tobacco users wishing to quit
- Technical assistance in design of optimal policies
- Cash on delivery aid for a country or sub-national unit to reduce smoking prevalence8
We do not have a good understanding of the likely costs or benefits of any of these approaches.
3. Who else is working on this?
The World Health Organization Framework Convention on Tobacco Control, to which more than 170 countries are signatories, lays out principles for the control of tobacco, which the MPOWER policies are designed to implement.9 The WHO’s Tobacco Free Initiative conducts ongoing work to limit the global burden of tobacco by building country capacity to combat tobacco use, improving tobacco surveillance, and advising countries on tobacco taxation.10
A pair of foundations also provide significant support:
- The Bloomberg Philanthropies have pledged $220 million over 4 years (~$55 million/year) to tobacco control efforts in low- and middle-income countries.11
- The Gates Foundation has pledged $125 million over 5 years (~$25 million/year) to tobacco control efforts in low- and middle-income countries.12
The Bloomberg Initiative to Reduce Tobacco Use supports a coalition of five partners:13
- World Lung Foundation and its partner the International Union Against Tuberculosis and Lung Disease
- Campaign for Tobacco-Free Kids
- World Health Organization
- Centers for Disease Control and Prevention Foundation
- Johns Hopkins Bloomberg School of Public Health
The Gates Foundation has funded a number of other organizations for work on global tobacco control efforts, including the American Cancer Society and the Southeast Asia Tobacco Control Alliance.14
Domestic civil society organizations in low- and middle-income countries also play an important role.15
Using fairly aggressive assumptions, Cynthia Callard of Physicians for a Smoke-Free Canada estimated that in 2008, global funding for tobacco control in middle- and low-income countries (including the Gates and Bloomberg funding discussed above) “is likely no greater than $240 million.”16 With a more conservative set of assumptions, Hana Ross and Michal Stoklosa of the American Cancer Society estimated that in 2008, global funding for tobacco control in middle- and low-income countries included $42 million in international assistance and $37 million in domestic public resources.17 Even on the higher funding estimate, tobacco control funding is approximately an order of magnitude less per person who suffers (i.e. smokes) or dies than funding for HIV/AIDS, malaria, or tuberculosis.18
It is not clear whether these estimates take into account funding by bilateral development agencies or development banks, and we do not have a sense of how taking into account such flows might affect the overall estimates.
The WHO estimates that implementing a portion of the MPOWER tobacco control policies in the 23 low-and middle-income countries that account for 80% of the developing world’s chronic disease burden would cost roughly $800 million/year.19
4. Questions for further investigation
Our research in this area has been relatively limited, and many important questions remain unanswered by our investigation.
Amongst other topics, further research on this cause might address:
- How strong is the evidence in favor of the MPOWER interventions? Are some interventions more important to implement than others?
- What impact has the large influx of funding into tobacco control efforts from the Gates and Bloomberg foundations had?
- Which of the strategies described above are most likely to be cost-effective?
5. Our process
We decided to look into tobacco control efforts in low- and middle-income countries because we had heard informally that tobacco was a large and growing cause of mortality globally and that it receives relatively little philanthropic funding. Our investigation mainly consisted of speaking with two individuals with knowledge of the field and some limited desk research.
|WHO report on the global tobacco epidemic, 2013||Source (archive)|
|WHO Fact Sheet on Tobacco 2013||Source (archive)|
|The Tobacco Atlas (2012)||Source (archive)|
|MPOWER: A policy package to reverse the tobacco epidemic||Source (archive)|
|Bloomberg Philanthropies 2011||Source (archive)|
|“Bloomberg Philanthropies Pledges $220 Million to Curb Tobacco Use Abroad”||Source (archive)|
|“Michael Bloomberg and Bill Gates Join to Combat Global Tobacco Epidemic”||Source (archive)|
|Gates Foundation Grants Database||Source|
|Callard 2010||Source (archive)|
|Ross and Stoklosa 2011||Source|
|Bollyky and Glassman 2012||Source (archive)|
|WHO Tobacco Free Initiative||Source (archive)|
|Asaria et al. 2007||Source (archive)|