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Cigarette smoking and other tobacco product use has been rising in most low and middle-income countries since the 1970s, in contrast to declines in tobacco consumption in high-income countries (Gajalakshmi, et al. 2000). Currently, the vast majority of the world’s 1.1 billion smokers are in low and middle-income countries. Freer trade in cigarettes and other tobacco products has contributed to the increased consumption in low and middle-income countries (Taylor, et al. 2000). Most smokers in high-income countries began smoking as teenagers, while those in low/middle-income countries began in there early twenties. The age of initiation in these countries, however, is falling. Moreover, in most countries today, the poor are significantly more likely to smoke than the rich. Because of the lags between tobacco use and its health consequences, about half of the 4 million tobacco-attributable deaths globally occur in high-income countries. On current smoking patterns, however, the public health toll from tobacco is rapidly shifting to the developing world. As Thun, et al. (2000) describe, there are four stages to the tobacco epidemic, with smoking among both men and women rising during the first two stages and then declining in the final two stages, but with tobacco-attributable deaths among men not declining until the fourth stage, while tobacco attributable deaths among women are often still rising during this stage. Much of Southeast Asia is currently in the second stage of the tobacco epidemic, the stage where smoking prevalence is rising and exceeds 50% in men and where smoking prevalence is beginning to increase among women. In addition, the first increases in tobacco-attributable deaths are beginning to be observed in the form of rising lung cancer rates among men (Thun, et al. 2000). In Cambodia, for example, a recent estimate of smoking prevalence among adult urban males was 64.7 percent, while that among rural males was 86.3 percent (Corrao, et al. 2000). Similarly, in Vietnam and Malaysia, recent estimates indicate that nearly three quarters and half of adult men, respectively are current smokers, while less than five percent of women currently smoke in both countries. Recent trends imply significant increases in tobacco product consumption throughout the region. For example, Argus Business Media Limited, in its World Tobacco File: Emerging Markets in Asia in 1997 report projected increases in per capita white stick cigarette consumption from 1996 to 2005 of 8.8, 10.7, 11.2, and 17.6 percent in Thailand, Vietnam, Malaysia, and Cambodia, respectively. Given their relatively early stage in the tobacco epidemic, effective tobacco control policies that result in adult smoking cessation and the prevention of youth smoking initiation can lead to significant health benefits. However, for most countries in this stage of the tobacco epidemic, tobacco control activities are usually limited or nonexistent, and there is relatively low public and political support for the adoption and implementation of effective tobacco control measures (Thun, et al. 2000). Much of this inactivity results from concerns that tobacco control interventions will have harmful economic consequences (Jha and Chaloupka 1999). For example, some policymakers fear that higher cigarette and other tobacco product taxes and strong tobacco control measures that would reduce cigarette smoking would result in massive job losses, substantial losses of government revenues, and significant increases in cigarette smuggling. Largely based on evidence from high-income countries, the World Bank and WHO have worked to address these and other myths concerning the economics of tobacco use and tobacco control (Jha and Chaloupka 1999, 2000). These efforts clearly indicate that the economic fears that have deterred policymakers from taking appropriate actions to reduce tobacco use are largely unfounded. Effective policies that significantly reduce the demand for tobacco products exist, including higher cigarette and other tobacco excise taxes, comprehensive limits on tobacco product advertising and promotion, the provision of information on the health consequences of tobacco use, strong restrictions on smoking in public places and worksites, and increased access to nicotine replacement and other cessation therapies. These policies could bring unprecedented health benefits without harming economies. Chaloupka, Jha, and their colleagues have continued this work through the formation of the International Tobacco Evidence Network which includes many of the economists and other policy researchers who participated in the efforts described above, as well as a growing number of others conducting tobacco-related economic research in an increasing number of countries. Much remains to be done. Of particular importance is the need for conducting research at the country and regional level to provide policymakers with the information that would allow them to adopt the most effective mix of tobacco control measures with a full understanding of the economic implications of these measures. This includes, for example, research that provides country-specific estimates of the price elasticity of cigarette demand and demand for other tobacco products, including research that examines the differential responses to price among important population subgroups, including the poor and the young. This type of research is critical in understanding the impact of tax increases on tobacco use, on revenues from tobacco taxes, on household spending patterns, and on the potential for smuggling in response to tax increases. Similarly, this includes research that estimates the health and other economic costs from tobacco use that would be of particular importance in determining appropriate cigarette excise tax rates and in understanding the impact of tobacco use on government spending. Additionally, it includes research on the cost-effectiveness of various tobacco control interventions that would provide information critical to developing the set of policy interventions that would maximize the impact of the relatively limited resources most governments commit to tobacco control activities. Likewise, it includes research that would look at the economic and health equity of tobacco control interventions (examining, for example, whether tax increases and other tobacco control interventions lead to disproportionate improvements in health among the poorest populations), as well as research on how the tobacco industry responds to these interventions (for example, by changing its marketing activities in response to new restrictions on tobacco advertising). Finally, it includes research that looks at a variety of issues related to the globalization of the tobacco industry, ranging from licit and illicit (i.e. smuggling) trade in tobacco products to the privatization of domestic tobacco monopolies. These are but a few examples of the types of research that is needed to inform the development of appropriate tobacco control activities at the country level. The Trading Tobacco for Health Initiative is an unprecedented effort to support this type of research, targeting Southeast Asia, with an initial focus on Cambodia, Malaysia, Thailand and Vietnam. During the first two years of this initiative, substantial progress has been made in developing capacity for conducting policy relevant, tobacco-related research in these countries through a series of training and technical assistance efforts. The next phase of TTFHI will continue and expand on these efforts and findings from the research supported by this program will begin to appear and impact on country and regional tobacco control efforts.
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