Global Tobacco Control: An integrated approach to global health policy

Abstract

Following the development discussion in the last volume on the ‘politics of health’, Jennifer Prah Ruger argues that the Framework Convention on Tobacco Control (FCTC) represents a shift in global health policy that recognizes the importance of addressing health needs on multiple fronts and integrating public policies into a comprehensive set of health improvement strategies. She argues that the FCTC provides a model for multifaceted approaches to health improvement that require simultaneous progress on various dimensions.

Introduction

In May 2003, the192-member World Health Assembly unanimously adopted the Framework Convention on Tobacco Control (FCTC) in an effort to curtail tobacco-related disease and death worldwide. The FCTC is a historic document as the ‘first international treaty negotiated under the auspices of the World Health Organization’ (WHO, 2003, http://www.who.int/mediacentre/releases/2003/prwha1/en/, accessed 03 Febuary 2004). It proposes measures to reduce the demand for tobacco through advertising, price and tax policies and to reduce supply by, for example, prohibiting smuggling and sales to and by minors (Yach, 2003). It represents a growing trend in development policy towards an alternative paradigm that is broad, integrated, and multifaceted (Stiglitz, 1998; Sen, 1999; Wolfensohn, 1999; Rodrik, 1999; Ruger, 2003, 2004a, b, d). It also relies heavily on cooperation and partnerships in ensuring that institutional comparative advantages are exploited and redundancies are eliminated. This alternative view appeals to a framework of development that relates to Amartya Sen’s capability approach (Sen, 1999). This view sees development as the expansion of individual freedom instead of judging development by gross national product or personal income. Similarly, it sees public health policy as expansion of individuals’ choices or opportunities for a healthy life (Ruger, 2003, 2004b, c), instead of judging health policy by health spending or defined benefits, important as these are (Ruger, 1997, 1998).

The FCTC represents a shift in global health policy that recognizes the importance of addressing health needs on multiple fronts and integrating public policies into a comprehensive set of health improvement strategies. Integrated public policy need not involve such formal connections as in the FCTC however, though such ties can be very useful. Less formal linkages can also be effective, as demonstrated by multifaceted approaches to health improvement that require simultaneous progress on various dimensions, and is the basis of the current recommendation to combat HIV/AIDS.

A new approach to public health

Adopting a multifaceted and integrated approach to health improvement requires rejecting a narrow view of health and its determinants and the philosophical foundations that support such a view. (Ruger, 2004b, in press) It has been known for some time that many important determinants of health lie outside the health-care sector (Marmot et al., 1995; Ruger, 2004b, c). Thus, health care, important as it is, cannot alone maintain good health and prevent and remedy illness that results from, say, tobacco use or HIV/AIDS. In North America, western Europe, Australia, Brazil, Senegal, Thailand, and Uganda, for example, the spread of HIV/AIDS has been slowed through multiple prevention strategies, including behaviour modification and health education, social, economic, and political environments that allow individuals to protect themselves against infection, condom promotion, HIV counselling and testing, blood safety, reduction in mother-to-child transmission, needle exchange programmes, and treatments for sexually transmitted infections (Ruger, 2004a; UN 2001, http://www.unaids.org/en/other/functionalities/ViewDocument.asp?href=http%3a%2f%2fgva-doc-owl%2fWEBcontent%2fDocuments%2fpub%2fPublications%2fFactSheets02%2fFS_prevention_en%26%2346%3bpdf, accessed 03 Febuary 2004).

Integrated sets of strategies have also been more effective than narrower approaches for controlling tobacco use in a number of countries (World Bank, 1999; Ruger, 2004c). Successful efforts have included simultaneous bans on advertising and promotion and on sales to children, mandatory health warnings, smoke-free environments, higher taxes on tobacco products, and investment in health education and smoking prevention and cessation programmes (World Bank, 1999; Ruger, 2004c). Through the FCTC, for example, ministries of health and health-related associations, such as physician groups, united with ministries of finance, economic planning, taxation, labour, industry, and education as well as with citizen groups and the private sector to create a coordinated national and international tobacco-control effort. Such efforts were instrumental in achieving multi-sectoral support for the framework (Yach et al., in press).

Development and health strategies

Integrated public policy involves more than integration of disease-specific interventions, however. It must also involve a country’s broader development strategies. For example, being a member of a socially disadvantaged group puts individuals at increased riskof smoking initiation and addiction, even in developed countries (Warner, 2000). Poverty, in particular, is increasingly associated with smoking initiation and continuation and poorer smokers are believed to be more dependent on nicotine than their non-poor counterparts (Warner, 2000). Smoking among adolescents is also highly correlated with socio-economic status and achievement and the strong influence of poverty and social disadvantage makes it difficult for young people to break the cycle of tobacco addiction that may have started generations before. At the same time improved economic, cultural, and social conditions for adults and children – through, for example, cultural disapproval of smoking; non-smoking expectations and workplace bans on smoking (Jarvis, 2004) – enhances the effectiveness of tobacco use prevention and treatment. In addition, real employment, political, and civil opportunities (Ruger, 2005b; Northridge, 2004) that empower individuals within society improve the odds of tobacco abstinence and cessation because such freedoms enable individuals to exercise greater control in choosing healthier life strategies (such as smoking abstinence) and conditions for themselves and those around them.

Integrated public policy therefore has, what may be called, horizontal and vertical dimensions, respectively (Ruger, 2004c). The horizontal dimension integrates policies across disease-specific activities, creating a comprehensive package of complementary interventions to prevent disease and promote health (Ruger, 2004c). The vertical dimension integrates domains of public policy that build sequentially upon each other (Ruger, 2004c). Improving an individual’s education and employment prospects, for example, can improve the health of herself and her family, which in turn can improve overall health within a society. Moreover, horizontal integration can be enhanced by vertical integration, and vice versa.

A third area of integration links institutions that focus on disease-specific issues to those that have broader development aims in a coordinated set of strategies. For example, government agencies can ban workplace smoking, while employers and insurers can expand access to cessation interventions. The shift in global health toward public–private partnerships reflects this view, but such efforts should be more closely linked with specific disease prevention efforts and broader development activities, as in the FCTC (Ruger, 2004c).

Integrated public policy is no panacea, however. Like all public policy strategies, its implementation will have unintended consequences and even pitfalls. For example, reductions in smoking due to workplace bans, movie ratings and higher taxes may be slow to materialize. It may also be difficult to coordinate many different strategies. Moreover, implementing strategies sequentially takes time and makes policies interdependent, which increases the difficulty of evaluating policies for systematic change.

A parallel shift towards integration and multiplicity has occurred in development policy more broadly and creates the foundation for these novel efforts in global tobacco control. At the World Bank, for example, the development agenda – although not without controversy and still evolving – has broadened to reflect a better understanding of poverty and its causes; recognizing that the experience and determinants of poverty are multidimensional (Wolfensohn, 1999). At the Bank, the process of development is now referred to as comprehensive development, which is holistic, integrated, and multidimensional, and balances the strengths of the market and of institutions and focuses on individuals in client countries (Wolfensohn, 1999). Improved health is central to this new agenda and tobacco control has been a key economic development project (Stiglitz, 1998; Wolfensohn, 1999; World Bank, 1999; Yach et al., in press; Ruger, 2005a). The Bank’s Comprehensive Development Framework (CDF) (Wolfensohn, 1999) encompasses these lessons and emphasizes close partnerships among development institutions to assist countries in enhancing growth and improving the well-being of their citizens. The Bank has worked extensively with WHO on global tobacco control efforts, especially in the area of macroeconomic analysis and efforts to establish the evidence base on the most effective methods of curbing the prevalence and consumption of tobacco products (World Bank, 1999; Jarvis, 2004). Two Bank documents in particular, Curbing the Epidemic (World Bank, 1999) and Tobacco Control in Developing Countries, document research results of the effectiveness of different methods of tobacco control, focusing especially on studies of the price elasticity of demand for tobacco projects in developing countries. Studies were conducted in Ukraine, Turkey, Sri Lanka, Indonesia, South Africa and Egypt, for example. The Bank also conducted analyses of household expenditure surveys in Bulgaria, Tajikistan, and Egypt to assess household spending on tobacco products by income group in those countries. Similarly, WHO considered tobacco control as one of its main areas of focus to improve public health worldwide during the Brundtland administration; an emphasis that laid the foundation for the FCTC.

Sustainable systems

From academia, key development scholars (Stiglitz, 1998; Rodrik, 1999; Sen, 1999) have proposed development frameworks recognizing that development requires multiple factors ranging from well-functioning and supervised financial systems to a sustainable environment. Most notable is Amartya Sen’s development paradigm (Sen, 1999), which views development as the expansion of individual freedoms, including individuals’ freedom from preventable diseases, such as those caused by excessive tobacco use. Sen’s development paradigm in particular recognizes the need to address basic needs, such as health, on multiple-fronts and to integrate public policies into a comprehensive set of development strategies (Sen, 1999; Ruger, 2003, 2004b, c). Such integration requires multiple institutions with complementary and comparatively advantageous roles. Lessons learned from 50 years of development experience and theory suggest, for example, that macroeconomic stability, liberalization and privatization – key components of the ‘Washington Consensus may still matter, but as Sen notes, development is multifaceted and comprehensive and our understanding of it must be integrated and inclusive (Sen, 1999). A number of key elements, including economic growth and stability, a thriving private sector, investment in people and physical assets, a sustainable environment, and fair institutions and policies, are necessary to promote prosperity, reduce poverty and improve human freedom.

The FCTC thus represents a paradigmatic shift in thinking about global tobacco control that has roots in shifts in global development policy more generally. This alternative framework is broad, integrated and multifaceted. These efforts have evolved steadily over the past decade and are based on empirical evidence and philosophical foundations about human well-being, including health, and the conditions necessary to improve people’s lives world-wide. While this new paradigm may not be a panacea and the outcomes of these efforts are yet to be fully realized, the case for a multifaceted and integrated approach to health improvement is emerging and is shaping a new development architecture for health (Ruger, 1998, 2004b, 2005a), as illustrated by the current tobacco control movement and its major product, the FCTC.