Anthony So

Anthony So, associate director of health equity at the Rockefeller Foundation, discussed this and other model programs related to tobacco control to an HSPH audience on September 8. In his lecture "Trading Tobacco for Health: Tackling Tobacco Use in Developing Countries," So outlined an ongoing initiative involving philanthropy, governments and non-governmental organizations (NGOs).

"Our goal is to enable developing countries to respond to the challenge of tobacco on their own terms and for the long-term," he explained.

HSPH Dean Barry Bloom introduced the guest speaker, praising So’s ability to untangle the complex issue in a manner that will help public health specialists understand the full scope of the problem.

Worldwide, tobacco claims a staggering number of lives, and the numbers are expected to escalate dramatically in the near future. More than 3 million people died of tobacco-related illnesses in 1990, So said. (An updated HSPH analysis just published in The Lancet indicates that nearly 5 million premature deaths were caused in 2000 as a result of cigarette smoking. See sidebar below.) By 2020, an estimated 8.5 million tobacco-related mortalities are projected. The number rockets to a projected 10 million people by 2030, with 7 out of 10 deaths expected to occur in developing countries.

"To put it in perspective, tobacco-related mortalities over the next 30 years will exceed the combined total from AIDS, TB, maternal mortality, homicide, suicide and automobile accidents," So noted.

He focused his lecture on Southeast Asia, where the region’s increased tobacco trade is thought to be the cause of a recent rise in smoking-related deaths. Unfortunately, he said, the capacity of cash-strapped nations to respond to rising morbidity and mortality is inadequate to counter the success of tobacco marketers.

Shops offer attractive promotional materials provided by tobacco companies. The cigarette makers sponsor local sports teams. They advertise in major media. Tobacco-control programs offer counter-advertising but often do not have the budgets with which to compete against tobacco company marketing campaigns.

Tobacco use disproportionately affects the poor, So said, and claims a substantial chunk of Southeast Asia’s per capita income, with the poor, the least educated and the least skilled its largest consumers.

The good news is that the four countries chosen so far to receive funding from the ‘Trading Tobacco for Health’ initiative–Thailand, Malaysia, Vietnam, and Cambodia–have made significant headway controlling tobacco use. So said he sees "a significant opportunity to build from this regional base over time." A number of model programs developed in the last three years are worth noting, he said.

In Cambodia, home of approximately 50,000 Buddhist monks, one noted religious figure involved in a successful monastery-based smoking cessation program recorded public service announcements that urged smokers in the larger community to follow his example and quit. His involvement, along with that of other monks, underscores how a culturally appropriate program can win converts in the war against tobacco, So said.

In Vietnam, school children are being asked to bring home pledge sheets for their parents to sign promising that the parents will not smoke in the house. Media messages will air during the campaign, and representatives of organizations, including the Women’s and Youth Union, will go door to door to discuss harms of secondhand smoke. The program has the dual effect of helping adults stop smoking while preventing children from ever starting, So said.

One of the best ways to stem tobacco use in the young and among the poor is to raise the price of cigarettes, he said. In Vietnam, partners of the South East Asia Tobacco Control Alliance (SEATCA)–including the World Health Organization, the Vietnam Committee on Smoking and Health, and PATH-Canada–have made a case for a tax increase on tobacco products, using local research and cross-national data. The work reached the attention of policymakers, including those at the Ministry of Finance, through a regionally hosted workshop on tobacco and taxes earlier this year–and to good effect. Vietnam has recently announced that a 10 percent value-added tax is slated to begin January 2004. SEATCA was created in 2000 after a regional group of governmental and non-governmental stakeholders met in Ayutthaya, Thailand to discuss their shared challenges from tobacco use and promotion.

In Thailand, anti-smoking factions successfully pressed for a 2 percent tobacco and alcohol tax to fund research and health promotion activities through a new national health promotion foundation, ThaiHealth.

In Malaysia, a clearinghouse on tobacco control has been launched at the Universiti sains Malaysia (University of the Sciences, Malaysia). A health promotion foundation, in part modeled after ThaiHealth, is also planned.

The next challenge is to bring more organizations and government agencies on board, helping them understand how tobacco control can be seen through the lens of their own work, So said. For example, agencies working to promote infant and maternal health can be called upon to draw attention to the link between maternal smoking and low birth-weight babies.

In addition, he said, he would like to identify novel places for smoking cessation interventions, as well as opportunities to piggyback tobacco control initiatives onto existing health programs.

So’s lecture was co-sponsored by the Dean’s Office, the Departments of Population and International Health and Health Policy and Management, the Division of Public Health Practice, and the Harvard Center for Cancer Prevention.

--PHC

Majid Ezzati