Tobacco and Public Health - TCSC Indonesia

PRABHAT JHA ET AL. 735
India (Gupta and Mehta 2000; Gajalakshmi et al. 2003), indicate that the overall risks of
smoking are about as great as in high-income countries such as the United States and
the United Kingdom (about one in two risk of death with persistent smoking). However,
the pattern of smoking-related diseases in these nations is substantially different. A
recent study in Chennai, India (Gajalakshmi et al. 2003) suggested that smoking
accounted for about half of the tuberculosis deaths. Smoking caused 12 per cent of male
tuberculosis deaths in China, but—in contrast to Western high-income countries, it
caused few deaths from ischemic heart disease (Liu et al. 1998). Given the recent trends
in smoking and the lags between smoking and disease onset, approximately 70 per cent
of the 10 million tobacco-attributable deaths expected in 2030 will take place in lowand
middle-income countries.
Smoking is more common among poor men than among rich men in nearly all
countries. In developed countries, smoking accounts for approximately half of the
mortality gap between rich and poor males (Bobak et al. 2000). For women, who have
generally been smoking in large numbers for a shorter period, the relationship between
smoking, smoking-attributable mortality, and socioeconomic status is more variable.
Interventions to reduce smoking
Tobacco use generates social costs that provide the rationale for government intervention
in the tobacco market. Poor understanding of the addictive nature of tobacco
products, particularly at the time of smoking initiation, coupled with insufficient
information about the health consequences of smoking gives additional reason for
government involvement (Warner et al. 1995; Jha et al. 2000c), particularly in low- and
middle-income countries where general awareness of the health risks is even lower
(Kenkel and Chen 2000).
In addition to preventing tobacco consumption among children, comprehensive
approaches focusing on smoking cessation are critical to near-term improvements in
public health. As illustrated by Fig. 42.1, a mix of tobacco control policies that is
effective only in reducing smoking initiation would have little impact on smokingattributable
deaths during the first half of the twenty-first century. The vast majority of
tobacco-attributed deaths over the next 50 years will occur among current smokers
(Peto and Lopez 2001). Studies in western populations have documented the
enormous benefits of quitting smoking, particularly before the onset of major diseases
(Donald et al. 2002). Thus, cessation among today’s smokers is key to progress in
tobacco control over the next few decades (Fig. 42.1).
Interventions in the tobacco market can be classified as demand side or supply side
interventions.
Demand side interventions
The effect of demand side interventions has been mostly examined in high-income
countries. Recent studies from low- and middle-income countries provide additional