Podcast Summary

The CGD Podcast

Episode: Tobacco: Control or Eradicate? – Podcast with David Sweanor and Bill Savedoff
Date: May 27, 2016
Host: Rajesh Merchandani (A)
Guests:

• David Sweanor (B), University of Ottawa, tobacco control policy expert
• Bill Savedoff (C), CGD Senior Fellow

Main Theme & Purpose

This episode explores the global challenge of tobacco use, particularly in low- and middle-income countries, and debates the most effective strategies for reducing harm: should policy aim for complete eradication of tobacco use, or prioritize harm reduction through alternatives like e-cigarettes and nicotine gum? The discussion leverages Canada's tobacco control experience and examines policy applicability in developing countries.

Key Discussion Points and Insights

1. The Global Tobacco Burden

• Smoking is projected to cause 1 billion premature deaths this century, with 80% of smokers living in low- and middle-income countries. The strain on health systems and economies is profound. [00:05]

2. Canada’s Approach to Tobacco Control

• Legal and Policy Reforms: Canada successfully reduced smoking by combining:
  • High taxes—"the most powerful tool" [03:05]
  • Restrictions on advertising and accessibility
  • Warning labels and public education
  • Smoking bans in public places to shift social attitudes
  • "The big breakthroughs come from giving people truthful information and giving the ability to act on it." – David Sweanor [03:37]
• Missed Opportunities: Early efforts to prioritize less harmful alternatives to cigarettes were overturned by industry challenges. Canada has not fully realized the potential of harm reduction strategies. [04:22]

3. Harm Reduction vs. Complete Cessation

• David Sweanor's Stance:
  • Harm reduction is common in public health and should be embraced for tobacco—focus on moving smokers to less harmful nicotine products.
  • "You get rid of the combustion, you get rid of the problem." – David Sweanor [05:50]
  • Nicotine, absent smoke, poses significantly less health risk.
• Bill Savedoff's Concerns:
  • Agrees that quitting nicotine entirely is ideal, but worries about unintended consequences of normalizing alternative nicotine products (e.g., e-cigarettes):
    • Could create new gateways into smoking or nicotine use, especially for youth.
    • Policymakers must distinguish between getting current smokers to quit and preventing initiation among new users.
  • "I would like to get them to quit, but I'm really concerned about the 3 million a year or so who are starting up each year." – Bill Savedoff [08:20]

4. The Developing Country Context

• Divergent Epidemic Stages:
  • Some countries (China, India, Indonesia) have high prevalence and need to resist tobacco industry influence and strengthen taxation.
  • Others (especially in Africa) are at an early stage, but facing rising prevalence.
  • "It's the big Mack truck coming down the road." – Bill Savedoff [09:36]
• Tailoring Strategies:
  • Need to balance initiation prevention, cessation, and harm reduction based on local context and market conditions.

5. Tax Policy and Regulation

• Differential Taxation:
  • Sweanor advocates for taxing tobacco/nicotine products based on their risk profile—lower taxes for less harmful products like e-cigarettes. [13:08]
  • Reference to a recent New England Journal of Medicine piece promoting this approach [13:10]
• Policy Complexity:
  • Savedoff worries this can complicate messaging and administration, especially in low-capacity countries. First focus should be broad, significant cigarette tax increases. [14:54]
  • "It's hard enough for us to get across to people the magnitude of the tobacco epidemic." – Bill Savedoff [14:34]

6. Applicability of Rich Country Policies to Developing Countries

• Sweanor refutes the idea that Canada's policies won't translate to other contexts, noting global adoption of measures like advertising bans and graphic warnings. [15:43]
• Success stories exist in both rich (Canada, US, France) and middle-income countries (Brazil, Turkey, South Africa, Uruguay) using classic "toolkit" approaches.

7. The Challenge of Innovation and the Future

• Both guests agree on the necessity of using all available policy tools (“like playing a deck of cards in poker”: prevention, cessation, protection, and risk reduction) but differ on how aggressively to incorporate innovation and alternatives.
• Savedoff expresses caution about overcomplicating strategies amid the need for urgent, clear action:
  • "The challenge David's kind of laying out there is, you know, it takes a lot to do these strategies. So what if you flooded your market or opened up to innovation in some of these nicotine delivery products? I'm hesitant to go there at this stage, but it's a very worthwhile challenge for us to think about." [17:35]

Notable Quotes & Memorable Moments

• David Sweanor on Harm Reduction:

  • "The nicotine that they need…is not particularly hazardous. It just would not be a huge cause of death if people were getting their nicotine without sucking the smoke into their lungs." [05:25]
  • "You get rid of the combustion, you get rid of the problem." [05:50]

• Bill Savedoff on Prevention vs. Harm Reduction:

  • "I would like to get them to quit, but I'm really concerned about the 3 million a year or so who are starting up each year." [08:20]
  • "It's the big Mack truck coming down the road." (on the imminent tobacco rise in African countries) [09:36]

• On Policy Transferability:

  • "There is no set template for any country, but… it is like playing that deck of cards in a poker game. You've got to look at your hand and figure out what should you do." – David Sweanor [15:47]
  • "The French will never give up cigarettes … But France has brought it down." – Bill Savedoff [16:56]
  • "The toolkit is there. They could use it. And it probably is going to be most effective..." [17:16]

Timestamps for Important Segments

• [00:05] — Introduction: Scale of the global tobacco death toll and focus on developing countries
• [01:43]-[05:50] — David Sweanor on Canada's tobacco control achievements and harm reduction philosophy
• [06:00]-[08:37] — Bill Savedoff's perspective: quitting vs. substitution, concerns about youth initiation
• [08:54]-[10:15] — Developing country dynamics, policy priorities, and the rise in tobacco use
• [13:08]-[15:29] — Differential taxation, risk-based policy nuance, and concerns about administrative complexity
• [15:43]-[17:35] — Transferability of policy lessons, innovation vs. classic strategies, and the "toolkit" for tobacco control

Conclusion

The episode presents a nuanced debate on the best strategies for tobacco control, juxtaposing Canada’s success with harm reduction and traditional measures against uncertainties around applying these approaches in developing economies. While all agree on the importance of multi-faceted, pragmatic interventions, the practicalities of policy, enforcement, and messaging in the developing world pose persistent challenges. The dialogue invites policymakers to consider a full spectrum approach—but reminds them to proceed with clear priorities and context-specific adaptation.