The next battles against tobacco must be fought in the world’s major cities

Global cities like New York and London were among the first to pioneer effective tobacco control policies — like smoke-free workplaces, public cessation services and higher tobacco taxes.

These life-saving policies were so successful that an international treaty called the Framework Convention on Tobacco Control was negotiated in 2003 to promote similar evidence-based policies throughout the world. Until recently, many assumed the 181 countries that ratified the treaty had benefitted from it.

This month we published new research in the British Medical Journal showing that a pre-existing decline in global cigarette consumption was not accelerated by this international tobacco control treaty.

Worse yet, our depressing findings show that while people are smoking less in richer countries like the United States and the United Kingdom, tobacco consumption is rising by over 500 cigarettes per adult in poorer countries like China, Indonesia and Vietnam.

These unexpected results raise two important questions: what could explain these global disparities in tobacco control, and what can be done to address them?

Tobacco taxes too low

Global disparities may largely be explained by shifting economic trends and governments’ different capabilities in implementing tobacco control policies.

Rapidly growing metropolises like Beijing, Jakarta and Ho Chi Minh City have not had the same success in protecting their residents against the dangers of tobacco as the richer early-adopting cities.

One major reason is that tobacco taxes in these cities are a fraction of what we know they should be and are not rising as quickly as incomes.

As a result, these cities will lose billions of dollars in lost productivity and health-care expenditures, and the number one preventable cause of premature death will grow worse every year for hundreds of millions of people.

Tax avoidance and smuggling

Yet these emerging cities are not necessarily themselves to blame. Our research, when combined with past studies on the tobacco industry, provides some of the first quantitative evidence for what economists would call an “equilibrium effect” in the tobacco market — whereby the implementation of tobacco control policies in richer countries incentivized tobacco companies to relocate their lobbying, marketing and promotion activities to poorer countries with far less stringent policies.

In fact, there is a tragic irony to this story: the oligopolies dominating the global tobacco market are all headquartered in the very cities that pioneered the tobacco control policies, and these policies now drive industry operations to emerging cities with far fewer protections against this deadly product.

Phillip Morris in New York. British American Tobacco and Imperial Tobacco in London. Japan Tobacco in Tokyo. Not only are these publicly traded companies leveraging capital from wealthy investors in these cities to worsen the tobacco epidemic abroad, they are repatriating billions of dollars back into these wealthy cities through systemic tax avoidance and international smuggling coordinated at the highest levels — all while aggressively fighting against effective tobacco control policies around the world.

One billion expected deaths

Our research demonstrates that the Framework Convention on Tobacco Control has not yet led to equitable protection against the harms of tobacco for the great cities of the world.

By 2044 there will be twice as many people living in the world’s cities as in rural areas, meaning we cannot leave any city behind if we have any hope of defeating the global tobacco epidemic.

The next stage of this long war must be fought city by city. Whether that means raising tobacco taxes in Beijing, curtailing industry marketing in Jakarta, requiring plain tobacco packaging in Ho Chi Minh City or taking legal action in New York and London — we all have a role to play in fighting to prevent the one billion deaths that are expected from tobacco in the 21st century.