Tobacco control and health equality

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Editorial

Tobacco control and health equality

Karen Slama

¹

The growing awareness of the damage caused by tobacco which occurred in the 1950s and 1960s came from data mostly about men in a few rich countries (1). Since then, studies have shown that the impact of tobacco use is similar across populations and nationalities: the health consequences now are visible in all groups and populations that have taken up smoking or other tobacco use (2). Tobacco use in richer countries was first adopted principally by men, then boys, then women, then girls, concomi- tantly spreading from richer to poorer segments of the society (3). A number of countries have promul- gated health promotion campaigns and enacted various tobacco control legislative measures to encourage modifications of smoking behaviour across the population, but the patterns of abandon- ing smoking are also greatly associated with social class and income. In 1984, a study from England found that while prevalence was dropping in the first three income quadrants, it had not dropped for men and had risen for women in the lowest-income quad- rant (4). Higher rates among poorer populations are found in both high- and low-income countries (5).

Although the history of tobacco use is culturally very different across cultures in low-income countries, the use of traditional and manufactured tobacco prod- ucts has, as in the richer countries, clustered in the lowest socio-economic classes based on level of education and income (6). The developing world cur- rently contributes more than half of all tobacco deaths (7), yet tobacco growing and manufacture are still called a source of investment for development, as tobacco companies based in rich countries have extended their markets throughout the world (8).

The very real failure to protect vulnerable populations has become more and more visible.

Since the end of the 1990s, the World Bank has recognized the damaging effects of tobacco use in low-income countries (9,10). In 2003, an analysis of consumption over time showed that tobacco use in

the world was increasing at a rate of more than 5%

per year, because of the growing use in low- and middle-income countries (11). Today, 80% of the more than 1.4 billion smokers are estimated to be living in low-income countries (7).

The combination of tobacco smoking and other tobacco use with poverty is potent. A ground-breaking study from Bangladesh showed that poor people who smoked were spending a large proportion of their income on tobacco, reducing family expenditures on food, education or health care (12). This was followed by similar findings from a variety of low-income countries (13). A recent study found that among Moroccans living on less than 1000 dirhams ($134) per month, smokers were spending about half of all of their disposable income on tobacco (14). A study from India demonstrated that smokers living in poverty were significantly more likely to be extremely underweight and undernourished, making them even more vulnerable not only to the diseases of tobacco, but to all the diseases of poverty (15).

Recognizing the devastating impact of tobacco on health and development in the world, negotiations were initiated by the WHO in 2000 to form an international instrument for coordinated activity to reduce tobacco mortality and morbidity and protect the citi- zens of the world (16). The resulting treaty, the Framework Convention on Tobacco Control (FCTC), entered into effect in 2005 and now counts 168 countries (as of Dec. 2009) as parties to the Convention.

The relationship between tobacco control and health equity looms large in poverty alleviation and developmental issues. The situation today is this:

richer inhabitants of richer nations have, in large numbers, stopped smoking and public opinion has deemed smoking to be anti-social and unacceptable in many circumstances; in low-income populations, however, smoking is still socially acceptable and uptake is growing or stable. Despite initiatives for tobacco control, tobacco use has become a strong

1. Consultant in tobacco control, France. ([email protected])

http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975909358242 http://ghp.sagepub.com

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determinant of health inequalities in low-income groups in rich countries and across the population in many low-income countries. Efforts to resolve such health inequalities are a necessity for successful tobacco control.

In March 2009, the 14^th World Conference on Tobacco or Health was held in Mumbai, in India.

The International Union for Health Promotion and Education (IUHPE) organized two sessions at that conference on the relationship between tobacco control and health equity and development issues.

These topics of considerable importance to the tobacco control movement are core issues to the work of the IUHPE. We are very pleased to be able to present to a larger audience much of the content of these sessions through a series of papers that form this special edition ofGlobal Health Promotion.

The first four articles in this issue of GHP look at health equity issues. The statistics of tobacco deaths are calculated as a proportion of mortality rates from major non-communicable diseases including a large number of cancers, and diseases principally affecting the heart and lungs. People with low income and low education are more likely to be affected by these diseases; tobacco use joins a host of other behaviours and circumstances that cause these diseases to occur and to more easily shorten the lifes- pan. Poverty is a major risk factor for ill health, and particularly in relation to infectious diseases, including tuberculosis. Although there have been indica- tions since the 1900s of a connection between tobacco smoking and tuberculosis (TB), the issue was only addressed by the WHO in 2007 with the publication of the WHO/the Union Monograph on TB and tobacco control (17), which provides evidence of greater risk among smokers than non-smokers of contracting and dying of tuberculosis. Kristen Hassmiller Lich and her colleagues present a com- pelling analysis of the consequence on tuberculosis rates of the presence or absence of effective tobacco control. The lessons of this analysis cannot be too strongly stated: people are not only at greater risk of dying of the major chronic degenerative diseases because of their smoking; in areas of high tuberculosis rates, they are also at greater risk of contracting and dying of TB. And TB rates can be reduced through strongly enforced tobacco control, a most important step towards reducing the gap in deaths from tuberculosis between the poor and others in low-income countries.

The paper by Martha Morrow and Simon Barraclough makes a very important point about the issue of tobacco and gender. In the early stages of tobacco control, women were not considered to be ‘at risk’, and there was inadequate information and action concerning the health impact of women’s and girls’

uptake and use of tobacco. This neglect was very harmful to women’s health and has led many actors in tobacco control to engage in ensuring that female activities and social roles in relation to tobacco use are measured and given their full importance as an integral part of plans for action. But, as indicated in this remarkable paper, the issue of gender does not concern only women. The socially learned cultural roles for both men and women are strong factors in explaining the high use of tobacco among men and the acceptance by women of men’s smoking in many Southeast Asian societies. Gender awareness is a necessary part of tobacco control, but it must be seen to encompass the social roles attributed both to women and also to men.

The paper by Shu-Hong Zhu and colleagues is an analysis of the effect of population-wide and strongly enforced tobacco control activities on the dif- ference in smoking prevalence rates between different educational levels, a known social determinant of health inequality. The paper shows very convinc- ingly that population-wide tobacco control activities such as those that have been used in California over the past 20 years influence behaviour of those with low education as much as those with high education levels. The multi-factoral nature of smoking and ces- sation, and particularly, the greater prevalence of smoking among those with low education, make success more difficult in this population than in more educated groups, but the impact of comprehensive programmes offer similar initial effects. The authors then go on to address the question of whether or not tobacco control can reduce the gap in prevalence rates between high and low education, and demon- strate that if programmes are equally effective in reducing rates between groups with high or low prevalence, then the absolute gap will grow. But the gap over time should not be the measure of success or failure in addressing health inequality. A better approach should be an examination of the relative percentage reduction in prevalence according to the high- and lower-education groups.

The paper by Simon Barraclough and Martha Morrow looks at the often intricate relationships K. Slama

IUHPE – Global Health Promotion Supp (1) 2010 4

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between international tobacco companies and governments, with examples from Southeast Asia.

Government’s inherent role accommodating different sectors of society is a constant risk for incoherent and ineffective policy measures. The relationship of the state to both very conflicting world-views embodied in tobacco control activities, on the one hand, and investment in or ownership of tobacco production, on the other, is demonstrated in this examination.

These relationships cast a long shadow over action on tobacco control, if there is, indeed, any such action. The paper is important in emphasizing the enormity of the task ahead for international tobacco control, even in the presence of the WHO Framework Convention on Tobacco Control (FCTC).

The remaining articles and commentaries address the issue of the FCTC and the potential and limits on its possibilities to protect vulnerable populations and have an impact on health equity.

Neil Collishaw presents a very complete picture of what the FCTC is attempting to do to reduce tobacco use in relation to the Millennium Development Goals (MDGs) which have a precise mandate to reduce poverty. Many people were aghast at the omission of any mention of action to reduce chronic diseases and the behaviours linked to those diseases within the MDGs. Collishaw points out the potential coherence of these two instruments in achieving better health equity, but cautions that impediments to success are constantly being confronted.

Fatimah El Awa presents the impact of the WHO FCTC on the activities of countries in the Eastern Mediterranean region of the WHO and states how the WHO is building health promotion and tobacco control in national settings with this instrument. This underlines the importance of the existence of the Convention, despite barriers to its full implementation.

Country policies are indeed influenced by the FCTC.

The next paper looks at governance issues related to the FCTC. Michael Sparks notes that the study of the role of different actors in promoting and enacting the measures of the FCTC indicates a new dynamic, in which organized civil society not only plays an advocacy role, but has joined with governments to ensure the enactment and the enforcement of the provisions of legislation prompted by the FCTC.

This is a new and very different approach to governance which has achieved widespread acknowledge- ment and adherence among people working in tobacco control, and is, indeed, consideredobvious

and necessary for successful tobacco control.

Nevertheless, this approach is only one of many that could have been taken. There was strong reticence among some of the actors involved in the negotiations of the FCTC regarding the activities of NGOs or civil society to influence the process or be involved in treaty development. The involvement of civil society in the governance of tobacco control is a useful model for other issues of health promotion.

Jeff Collin, in his commentary, notes that the FCTC

‘exemplifies the major challenges involved in attain- ing coherence across the health and development agendas of states and international organizations’ in light of often contradictory trade and economic issues. Disentangling the conflicting goals of international agreements and elevating the importance of international health through tobacco control is clearly a goal that must be more thoroughly under- taken by tobacco control advocates.

Health promotion activities seek ways to fight inequalities in health, and a major tenet has been to focus on what people who are the victims of health inequalities want and perceive themselves to need.

Tobacco control per se is not always high on such a list of issues, but people do want better health and a better quality of life, a major outcome of effective tobacco control. This dichotomy must be more fully addressed by people working to alleviate health dis- parities through effective health promotion. The final paper in this supplement is a commentary by Vivian Lin, who presents a view of the FCTC and tobacco control from the health promotion side, and suggests a number of possible factors in understanding where they connect and where they do not connect, and how health promotion can build on this greater understanding as it develops activities designed to promote and build health equity.

In conclusion, tobacco use is a major source of health inequality for people of low socio-economic status throughout the world. Among those with low income or low education, smokers have higher risks of dying from a major chronic disease and from tuberculosis.

Comprehensive, population-wide tobacco control can influence people’s tobacco use similarly at all social and economic levels. Tobacco control has been successful in reducing the legitimacy of smoking as a behav- ioural choice in many countries, and the development of the WHO FCTC has placed tobacco control very high on the international health agenda. Some of the major issues to be addressed to successfully reduce Editorial

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deaths and diseases among all populations, including the poorest, are gender roles of both men and women, the corrupting influence of the tobacco industry on government, and conflicting perceptions in a globalizing world. The WHO FCTC is a remarkable public health treaty with the potential of addressing health equity and development issues, but only if incoherence with other international instruments is counteracted, and organized civil society continues to work on both advocacy and technical support for national programmes. Health promotion must consider the best way to address the full spectrum of social determinants of ill health and early death that disproportionately affect low socio- economic smokers.

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K. Slama