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The CGD Podcast
Tobacco: Control or Eradicate? – Podcast with David Sweanor and Bill Savedoff
00:18:45
A billion premature deaths this century – that’s the estimated toll of smoking. One solution is to encourage smokers to switch to less harmful nicotine delivery systems, like e-cigarettes. But does switching our focus to harm reduction mean...
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- [00:05]
A
Hello and thanks for joining me for the podcast from cgd, the center for Global Development. I'm Rajesh Merchandani. Each week we examine a different area of our work on international development. We bring you new ideas and policy solutions aimed at making our globalized world fairer for everyone. Today I want you to get your head around this idea. A big billion premature deaths this century, it's inconceivable, isn't it? But that's the projection for the effects of smoking. And with 80% of the world's smokers now living in low to middle income countries, that's a huge problem for the developing world. Not only in terms of the numbers of people who could die, but also the lost economic output for those countries and the enormous costs on already strained health budgets of treating illnesses associated with smoking. So what's the solution? Well, we've talked before on this podcast with CGD Senior Fellow Bill Savadoff about how increasing taxes on tobacco can change people's smoking behaviour, can turn them away from nicotine. But today we're going to hear a slightly different view. Professor David Sweener from the University of Ottawa helped develop Canada's tobacco control laws, which include taxing cigarettes, but which also focus on encouraging smokers to switch to to less harmful tobacco products like e cigarettes or nicotine gum. David and Bill are both with me in the studio today. Bill, David, great to see you. Thanks for joining me.
- [01:30]
B
Good being here.
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C
Thanks Rijos.
- [01:32]
A
David, let's start with you. Now. You helped Canada design tobacco control laws as well as a few other countries. But let's talk about Canada's experience. First of all, is Canada winning the fight against tobacco and if so, how?
- [01:44]
B
Well, that's a really easy question to answer. Yes and no. We've done a great job in reducing smoking compared to what has been seen in other countries, certainly compared to where we were when I started at the beginning of the 80s when 42% of 15 to 19 year olds in Canada were daily smokers. It's down to a tiny fraction of that now. We had the highest per capita consumption of cigarettes anywhere outside of the then Eastern bloc. We grew more tobacco per capita than the United States. We had three sitting senators who were on the boards of directors of cigarette companies. There was virtually no constraints on where anybody would smoke. The packages had no warnings other than a bit of a joke on the side that the industry put there saying health and welfare Canada advises that danger to health increases with amount smoked. Avoid inhaling in small print, suitably understated for Canada. Yes. And it was a matter of how do you counter these things. And my role as a lawyer going to work with anti smoking organizations was that you do that through policy. You need to change laws in order to change the environment in a way that changes behavior. So that is things like price, which is by far and away the most powerful tool that we ever used and certainly anybody's used to date. But that also includes where and how the product can be sold, to whom can it be sold, at what age, Things that just have the accessibility of the product better reflect the risk of the product. And then you want to do things about the information on the product. So when you've got huge lifestyle advertisements basically everywhere, when cigarettes are sold on countertops of corner stores like candy, when sports is used to promote smoking, you've created a social environment that negates the health message. So how do you change that? The big breakthroughs come from giving people truthful information and giving the ability to act on it. So on top of dealing with accessibility and the issues of information, we dealt with protection of others. And that was huge in changing social attitudes. So you want to protect people from secondhand smoke. The fourth area that we are still struggling with actually is the product itself. We did have a law passed in the 1980s that gave a put cigarettes at a disadvantage compared to other products that would be less hazardous and could be used in place of a cigarette. But the tobacco companies managed to challenge that law and get it thrown out. And the government came back with a law that no longer had that provision.
- [04:22]
A
So things that could be used in place of a cigarette. You mean things like nicotine gum?
- [04:27]
B
Yes, but we have not done a good job of replacing cigarettes. So the issue of risk reduction is something that's talked about. It's not acted on nearly enough.
- [04:38]
A
Do you think that what are called tobacco harm reduction strategies, namely officiales for e cigarettes or nicotine gum, do you think that's a good thing to have to make it easier for people to. Or cheaper for people to use those things rather than cigarettes?
- [04:54]
B
Sure. I mean, the reality is in public health we use harm reduction on everything. I mean, it's just one of the things we take into account. We've done phenomenal work in dealing with HIV aids. We've done phenomenal work on automobile accidents, industrial equipment, food processing. I mean, just a whole range of things. Children's sleepwear. We can go on and on about any product that's on the market. We try to reduce the risk as much as we can for the people who are still going to use that product or engage in that activity. When we look at cigarettes, we have such huge potential because we know not just that cigarettes kill people in extraordinary numbers, but we know why, you know, and it's happening because they're sucking smoke into their lungs. The nicotine that they need, which is the primary reason people smoke 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. You deal with, you know, a few residual things like preventing formation, nitrosamines, heavy metals, et cetera, but things are fairly easily dealt with. You get rid of the combustion, you get rid of the problem.
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A
Okay, this is where I want to bring in Bill. Do you agree with that or do you think it would be better to get people off nicotine entirely?
- [06:10]
C
I think that David might disagree. I think he would agree that it would be great to get people off nicotine entirely. So this sort of that agreement, and it's more the question of the strategy, it seems to me what Davis talked about, what Canada did and what other countries have done to reduce the tobacco epidemic. I mean, if you look at Canada, us, France, you see this huge increase in smoking and then 20 years later, huge increases in lung cancer rates, along with other kinds of cancers and cardiovascular diseases. And then once countries started doing the labels, restricting access, smoke free public places, helping people quit and raising taxes, you see the consumption decline and subsequently the lung cancer rates coming down. So this sort of the sense is like, it would be great to get people off nicotine because then they wouldn't be smoking. And my focus has been more on what really got that sort of turned the curve on the epidemic. And a large part of that, from what I've seen or what I think, is that it was a matter of cigarettes becoming very cool or governments actually promoting it. Like, you know, handing out cigarettes to GIs during World War II was a big thing in the US and so the question in my mind is if you make space for people to have alternative nicotine delivery things, whether it's, I mean, chewing tobacco is also harmful, but there are other kinds of chewing tobaccos or other things that aren't like necessarily like patches that need, what do you call it, prescriptions or something like that. There are other substances, ways of getting nicotine that aren't as harmful as smoking. And the concern I have is if you open up the space for that, aren't you kind of like. It's kind of like the gateway drug argument, which I Don't really buy when.
- [07:57]
B
It comes to this is why I'm.
- [07:59]
C
Kind of uncomfortable making this point. But it's this idea that if people start on E cigarettes, then you start seeing people puffing in public. And does that start making the idea of puffing a cigarette, even in public, private, more attractive? So to me that the critical thing, sort of, and David and I have had these arguments is like, we have almost a billion people in the world smoking right now. 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. And so I'm kind of concerned what happens with these, these alternatives, these harm reduction strategies. If you're getting people off one kind of nicotine onto another, what happens to that, that initial group that's starting up? That's where I'm most concerned.
- [08:37]
A
And how does that relate to the experience of developing countries? Getting back to CGD's area of focus, the massive increase in numbers in developing countries who are starting to smoke and the fact that 80% of the world smokers now live in low or middle income countries.
- [08:55]
C
So I think here there's sort of like a maybe I would distinguish two different categories. There are countries that are very far advanced in the tobacco epidemic, like Indonesia and China and India, where it seems to me the role of the richer countries has to be in helping them resist the misinformation of the tobacco companies. Helping them with the, I mean, the World bank, the imf, these other agencies should be possible to help them improve their capacity to tax and to adopt smart taxes and all this stuff. There's another category, countries. They're like, I think 25 countries in Africa that have fairly low prevalence of smoking at this stage, but the prevalence is actually increasing. And so the new smoker issue and the idea that you're in an early stage of the tobacco epidemic in these countries is where I think it's less clear to people that there's a huge problem coming down the road. But boy, you know, it's the big Mack truck coming down the road. And that's where I think the initiation issue is probably the largest. Now, how those play out. I mean, in terms of E cigarettes in particular, which is sort of a new kid on the block, but also with other kinds of chewing tobacco or chewing substances or things like that that give you nicotine without the toxic chemicals or the hazardous smoke or things like that. That's another question.
- [10:16]
A
What do you think the answer is?
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B
Well, I think like any area of public Health. There's a tendency when you get involved in a field to think something, somehow this is magically different than any other field. And that's almost never the case. So usually it's like watching the same Shakespearean play you've already seen 30 times. And if the guy beside you says, I think Julius Caesar's going to be okay this time, say it doesn't actually work that way. That when we see anything that's causing death, injury, disease, we have four broad areas of intervention. You do things that try to prevent people from ever starting. You do things to get the people who are engaged in activity to stop. You protect third parties from the harms caused by that activity and reduce the risk for the people who are still going to engage in the activity. And whether that's people having sex with strangers or people using IV drugs or people playing rugby, it doesn't matter. You know, you just, you look at all of those things and I think intelligent policy formation is about using them in an interactive way. So obviously, if you have a market where there is very little smoking now, but there's a risk that it's going to take off, surely doing things to prevent the onset of smoking, you know, what you do with the taxes, preventing advertising, that sort of thing, is incredibly important.
- [11:28]
A
So particularly relevant to developing countries.
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B
Well, yes, and then. But then it also depends on the country because many countries already, you know, though, they're low income, have very high rates of smoking, but it's low daily use because it's constrained by economics. As their incomes go up and you start hitting like a GDP per capita threshold of US$1,000 equivalent smoking takes off because all these people who are smoking two or three a day are now able to smoke a pack a day. What do you do to.
- [11:53]
A
That's borne out by the numbers. Is it $1,000 a year?
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B
Well, there's different estimates, but around $1,000 a year is one of the things we've looked at.
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A
Because people can afford less.
- [12:01]
B
Yeah, exactly. There's more disposable income. But if you look at where are our opportunities in this. I look at those four different interventions we do in public health as being like the four suits of a deck of cards. If you're a good poker player, you use all four. It doesn't mean that you put an emphasis on one of them or only pick three out of the four. You use all four. So if we look at risk reduction, we have many developing countries where there is use of alternative forms of tobacco, oral forms of tobacco, often with very High toxicant levels. We know that you can greatly reduce those levels. And we've seen it in places like Sweden. There's manufacturing standards you can use. As those companies start to modernize, consolidate, we have the ability to having those sorts of standards and preventing people ever transitioning onto cigarettes. Because you can also use things like differential taxation to say we can make it far less likely somebody who decided to smoke cigarettes when they can buy whatever's in that domestic market that's non combustible and we can greatly reduce the risk of the non combustible product.
- [13:08]
A
So lower taxes on things like e cigarettes.
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B
Yeah. Differential taxation. There's an article, a commentary Frank Schlupke, Ken Warner and I had in the New England Journal of Medicine just a few months ago that was pushing exactly this point that we need to use things like differential taxation rather than treating it all the same, because it isn't all the same. Let's tax on the basis of relative risk. And if we did that, how many people could we move either totally off any form of nicotine, but certainly for those who are still going to use a nicotinic product, moves them to the least hazardous product possible.
- [13:39]
A
Bill.
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C
There's a real appeal to me from the way David throws this out there, because as he said, you know, you've seen this picture before, but I also have this gut reaction that tobacco is really different. There is something significantly different about nicotine in terms of its addictiveness and the dose effect of smoking. So when he talks about alternatives, he's basically talking about creating a kind of continuum or a sense of that there are these alternatives and we can do the tax, restructure taxes to take advantage of this and get people to respond in ways that reduce harm. I get that. And my first reaction when I read the article was this is too complicated that it's hard enough for us to get across to people the magnitude of the tobacco epidemic. It's hard enough to get them to raise taxes in the first place on cigarettes, which are the real harmful product out there. And so I was listening to everything, like, that's a neat approach, but are we ready for that? Is Mozambique ready for that? Is this something that we'd be able to handle and actually manage in that scale? So I kind of.
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A
What do you mean, are they ready for that?
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C
To me, the first step is raising taxes and raising taxes in a smart way on cigarettes. And I'm concerned that if we start sending a message that you should raise taxes, but not only these four things that we know are really Good about taxes on cigarettes. But you should also make sure there's a separate category for smokeless tobacco. For E cigarettes, you start differentiating tax structures, it becomes more difficult to administer them. But in my mind it's more from the policy perspective. How do you sell it to the politicians?
- [15:29]
A
Okay, so we don't have a lot of time left. Let me just bring it back to your experience, David. In Canada, is it applicable to countries in the developing world? I mean, many people will say what works in Canada just works in. No.
- [15:43]
B
I mean, the cigarette companies used to say that when we move to things like getting smoking off airplanes and getting graphic warnings on packages and banning tobacco advertising that you might be able to do that in Canada. It's not going to happen anywhere else. And of course we've had those measures and the same with increasing cigarette taxes. We've seen the measures all over the world. I think it's a matter of looking strategically at this. There is no set template for any country, but there's again, 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. And there are lessons that we can pick up from Canada that are applicable to other countries. There's lessons we stole from other countries that were applicable to Canada. Thailand did a wonderful job dividing the tobacco industry using legislation that I'd helped draft in Canada. But to say, gee, not all cigarette companies are the same. I mean, some of them will actually support some measures because it'll screw their, their competitors. Maybe we can turn that to an advantage. So there's many, many lessons that we can learn. And we're constantly experimenting to see what works the best.
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C
And I think that's a fabulous sort of challenge for us to think about. Is there a leapfrog strategy here? And I guess I've just gone through this process of watching, you know, when you say, what are the stories from Canada? Well, Canada and US and Europe, essentially. I remember talking to somebody from France in 2000. French will never give up cigarettes. We're not as individualistic as you. We're not. We don't listen to the government the way you Americans do. I thought that was a pretty funny thing. But France has brought it down. And then we have examples now with South Africa and with Turkey and Brazil has done a phenomenal job. So countries, developing countries don't have to look to the rich countries to say, does this work somewhere? They can look at other low and middle income countries. Uruguay, well, the higher income, but plenty of countries out there who have done a lot of stuff using what are kind of the old tools at this stage, the warning packages, plain packaging, banning smoking in public places, helping people quit, raising price. So that tool packet, toolkit is there. They could use it. And it probably is going to be most effective in those cases. The challenge David's kind of laying out there is, you know, it, 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.
- [18:08]
A
Okay. David Sweener from the University of Ottawa, Bill Savadoff, my CGD colleague and pal. Thank you both for joining me.
- [18:16]
B
Great being here.
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C
Glad to be here.
- [18:17]
A
You can read more about Bill's work on tobacco and tobacco taxes on our website, cgdev.org you can also subscribe to this podcast via our website and also find us on itunes. I hope you've enjoyed it. Please join me, Rajesh Merchandani, for the next podcast from the center for Global Development.