What is the problem?

The World Health Organization (WHO) estimates that tobacco is the largest cause of preventable death in the world. Smoking is responsible for almost 6 million deaths each year or the loss of 140 million years of healthy life, with nearly 80% of the burden falling on low- and middle- income countries (LMIC)¹, a burden amounting to more than malaria and HIV combined.² Each death as a result of pack-a-day smoking shortens life by around 10 years, as shown by data in the United States.³

Collectively, smoking is responsible for 5-6% of all ill health globally according to the Global Burden of Disease study, and its share is rising over time.

Why is this problem pressing?

What is our recommendation based on?

Many in the development⁴ and public health⁵ fields see the problem as an effective intervention for improving health. Reviews by global health charity evaluators and foundations Open Philanthropy, Giving What We Can, Copenhagen Consensus and the Centre for Global Development (CGD) were mostly positive that tobacco control is a cost-effective public health intervention, with CGD calling tobacco taxes “The Single Best Health Policy in the World”. This page is largely based on their research.

That the Gates Foundation, has committed US$125 million over 5 years, and the Bloomberg Foundation has committed US$220 million over 4 years provides confidence that respected philanthropists see this as a pressing issue.

Why is it pressing?

Tobacco use is increasing in low- and middle-income countries and if no action is taken, the number of annual tobacco deaths is projected to rise to more than 8 million by 2030, amounting to the loss of more than 200 million years of healthy life.⁶ The Copenhagen Consensus Centre researchers estimate a total economic loss from tobacco of about 12.7 trillion dollars over the next 20 years – or about 1.3% of global GDP annually – as a result of tobacco causing one-third of deaths from vascular disease, half the cancers and 60% of chronic respiratory diseases.⁷

Furthermore, it is clear how tobacco use can be reduced, and many countries have succeeded in significantly reducing smoking rates. Taxing tobacco products seems to reduce consumption by about 4% for every 10% increase in price.⁸ Such a policy also costs the government nothing – rather it raises revenue. The main limiting factor is political enthusiasm for policies of this kind, which may be resisted by tobacco companies, smokers themselves and those who oppose interfering with people’s choice to smoke.

Despite the above, many developing countries do not have effective anti-tobacco programs. For example, The WHO Global Adult Tobacco Survey for China showed that only 23% of Chinese adults knew that smoking caused lung cancer, heart attacks and strokes. ⁹ The taxation share of the cost of a pack of cigarettes in China is also only 40%, significantly lower than in most developed countries and the level recommended by the WHO (75%).¹⁰

Efforts we could identify to discourage smoking amount to less than $1 per smoker in the developing world per year.

What are the major arguments against it being pressing?

• Tobacco companies will resist attempts to regulate cigarettes, making lobbying efforts challenging.
• There are already substantial efforts being made by some funders and public health experts to solve this problem (see “Who else is working on this problem?”).
• Some believe it is undesirably paternalistic to prevent people from smoking if they choose to do so, or even that it is rational to smoke given the enjoyment people get from it.
• In practice it may not be practical for our mostly English-speaking readers to influence tobacco policy in countries like China, where most of the growth in smoking is occurring. China is particularly interesting because all tobacco is sold by the government, and smoking accounts for 7-10% of central government revenue, suggesting there will be many interest groups to compete with on the issue.¹¹
• It might turn out that improving health does not much affect the long term progress or direction of human civilization, making it less important than it would seem based on its short term effect on welfare.

Key judgement calls made to prioritise this problem

• Attempts to get policy change that discourages tobacco smoking will sometimes work at a reasonable cost.
• It is good to discourage people from smoking, because the health damage exceeds any gain people get from enjoying smoking.
• There are developing countries available that would listen to external experts to help them set tobacco control policies.

What can you do about this problem?

What’s most needed to contribute to this problem?

Most methods for reducing tobacco deaths are relatively well known and have been tested in developed countries. For example, the ‘MPOWER’ package of policies developed by the World Health Organisation¹ recommends the following:

• Monitor tobacco use and prevention policies
• Protect people from secondhand tobacco smoke
• Offer help to quit tobacco use
• Warn about the dangers of tobacco
• Enforce bans on tobacco advertising, promotion and sponsorship
• Raise taxes on tobacco.

This approach and the likely impacts is described in detail in a recent WHO report.¹⁰

Promotion of electronic cigarettes is a new and potentially valuable way of helping people quit smoking, though controversial.¹²

As a result of the fact that the interventions are quite well studied and unlikely to be dramatically improved, implementation seems to be the key issue. This means designing and advocating for better government policy through public service, academia, think tanks and political parties.

Given the significant amounts of funding that have recently been made available (see ‘Who is working on this problem, below), this area is more likely talent constrained.

What skill sets and resources are most needed?

People with experience in:

• Health and economic policy
  • Knowledge of appropriate policy responses
  • Influence to implement or promote changes
• Public health
  • Improving our knowledge of the effectiveness, and cost-effectiveness of each intervention to reduce tobacco consumption

Who is working on this problem?

• National governments, in particular health departments, many of whom have programs to discourage smoking.
• The World Health Organization provides support to countries that want to reduce tobacco use.
• A pair of foundations also provide significant support:
  • The Bloomberg Philanthropies have pledged US$220 million over 4 years (~$55 million/year) to tobacco control efforts in low- and middle-income countries.
  • The Gates Foundation has pledged US$125 million over 5 years (~$25 million/year) to tobacco control efforts in low- and middle-income countries.

Including academics and public servants working on tobacco control along with philanthropic giving, we estimate that the resources going directly towards anti-smoking efforts are between US$100 – US$1,000 million per year.¹³

In considering how neglected the cause is, we should not forget supporters in the general public, who discourage people from smoking or vote in support of voting cessation policies, though we are not sure how to value them.

What can you concretely do to help?

• Complete graduate studies in policy, public health, evidence based social policy or economics.
• Conduct academic research into finding the most effective and cost-effective tobacco control policies; or study how those policies can be promoted in countries that do not yet have them.
• Apply to work at one of these organisations:
  • Gates Foundation
  • Bloomberg Foundation
  • World Lung Foundation
  • Campaign for Tobacco-Free Kids
  • World Health Organization
  • Centers for Disease Control and Prevention Foundation
  • Johns Hopkins Bloomberg School of Public Health

A wide range of positions with a public platform can be applied part time to the problem of tobacco control. For example, someone could use their skills as:

• a journalist to report on tobacco as a public health issue and to push for enforcement of adopted policies, or to help other journalists do so;
• an academic or other researcher could write up policy proposals for a think tank;
• a politician to push for evidence based tobacco reduction or cessation policies; or
• a grassroots activist to raise the level of attention devoted to tobacco use.

These kinds of activism are particularly promising if you already have local experience in a poorer country that has high smoking rates. If you are in a position to do these things soon you could apply for a grant from the foundations listed above.

Finally, someone could earn to give and themselves donate to anti-tobacco organisations or campaigns. We have not investigated opportunities for philanthropy in this area, but some charities do accept donations, such as the Campaign for Tobacco-Free Kids. One could also simply donate to whichever projects the larger foundations in this area make grants to.

Further reading

• Open Philanthropy report on Tobacco Control in Low- and Middle-Income Countries.
• WHO Fact Sheet on Tobacco 2015.
• Centre for Global Development policy paper, The Single Best Health Policy in the World: Tobacco Taxes.
• Giving What We Can’s report on whether tobacco is a best buy for the developing world.