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Tobacco Control in Low- and Middle-Income Countries

This is a writeup of a shallow investigation, a brief look at an area that we use to decide how to prioritize further research.

In a nutshell

  • What is the problem? The World Health Organization (WHO) estimates that tobacco is the largest cause of preventable death in the world, responsible for almost 6 million deaths each year, with nearly 80% of the burden falling on low- and middle- income countries.
  • What are possible interventions? There are a variety of policies, including increased taxes on tobacco, that the WHO reports reduce tobacco use. A philanthropist could undertake any of a variety of strategies to attempt to ensure passage and enforcement of such policies. We do not have a good sense of the likely returns to the different potential strategies.
  • Who else is working on it? The Bloomberg and Gates foundations each devote significant funding to tobacco control efforts, perhaps totaling about $80 million per year, working with an international coalition of partners. We do not have a systematic accounting of funding from other sources, but overall expect that funding for tobacco control efforts is about an order of magnitude less than funding for malaria or tuberculosis on a per-person-affected basis.

Published: November 2013

What is the problem?

The World Health Organization estimates that tobacco is the largest cause of preventable death in the world, responsible for nearly 6 million deaths each year, with nearly 80% of the burden falling on low- and middle- income countries.1 Most of these deaths are the result of tobacco use (primarily but not exclusively smoking), but about 600,000 a year are reportedly due to second-hand smoke.2 If no action is taken, the number of annual tobacco deaths is projected to rise to more than 8 million by 2030.3

The prevalence of smoking varies, amongst other dimensions, by gender and country income:4

  • Amongst adult men, the prevalence of smoking is higher in middle- and high-income countries (34% and 30%, respectively) than in low-income countries (21%).
  • Amongst adult women, the prevalence of smoking is higher in high-income countries (19%) than low- and middle-income countries (3% and 5%, respectively).

What are possible interventions?

The World Health Organization has developed MPOWER, a package of six policy interventions that are believed to reduce tobacco use.5 The MPOWER package of policies includes:6

  • Monitoring tobacco use and prevention policies
  • Protecting people from tobacco use
  • Offering help to quit tobacco use
  • Warning about the dangers of tobacco
  • Enforcing bans on tobacco advertising, promotion and sponsorship
  • Raising taxes on tobacco

To support the adoption and enforcement of these policies around the world, a philanthropist could support any of a variety of activities:7

  • Improved monitoring of tobacco usage globally
  • Training for journalists to report on tobacco as a public health issue and to push for enforcement of adopted policies
  • Mass media advertising to make people more aware of the dangers of tobacco and to mobilize support for a particular policy agenda
  • Targeted outreach to decision-makers in governments
  • Grassroots activism aimed at raising the level of attention devoted to tobacco use
  • Programs to support tobacco users wishing to quit
  • Technical assistance in design of optimal policies
  • Cash on delivery aid for a country or sub-national unit to reduce smoking prevalence8

We do not have a good understanding of the likely costs or benefits of any of these approaches.

Who else is working on this?

The World Health Organization Framework Convention on Tobacco Control, to which more than 170 countries are signatories, lays out principles for the control of tobacco, which the MPOWER policies are designed to implement.9 The WHO’s Tobacco Free Initiative conducts ongoing work to limit the global burden of tobacco by building country capacity to combat tobacco use, improving tobacco surveillance, and advising countries on tobacco taxation.10

A pair of foundations also provide significant support:

  • The Bloomberg Philanthropies have pledged $220 million over 4 years (~$55 million/year) to tobacco control efforts in low- and middle-income countries.11

  • The Gates Foundation has pledged $125 million over 5 years (~$25 million/year) to tobacco control efforts in low- and middle-income countries.12

The Bloomberg Initiative to Reduce Tobacco Use supports a coalition of five partners:13

  • World Lung Foundation and its partner the International Union Against Tuberculosis and Lung Disease
  • Campaign for Tobacco-Free Kids
  • World Health Organization
  • Centers for Disease Control and Prevention Foundation
  • Johns Hopkins Bloomberg School of Public Health

The Gates Foundation has funded a number of other organizations for work on global tobacco control efforts, including the American Cancer Society and the Southeast Asia Tobacco Control Alliance.14

Domestic civil society organizations in low- and middle-income countries also play an important role.15

Using fairly aggressive assumptions, Cynthia Callard of Physicians for a Smoke-Free Canada estimated that in 2008, global funding for tobacco control in middle- and low-income countries (including the Gates and Bloomberg funding discussed above) “is likely no greater than $240 million.”16 With a more conservative set of assumptions, Hana Ross and Michal Stoklosa of the American Cancer Society estimated that in 2008, global funding for tobacco control in middle- and low-income countries included $42 million in international assistance and $37 million in domestic public resources.17 Even on the higher funding estimate, tobacco control funding is approximately an order of magnitude less per person who suffers (i.e. smokes) or dies than funding for HIV/AIDS, malaria, or tuberculosis.18

It is not clear whether these estimates take into account funding by bilateral development agencies or development banks, and we do not have a sense of how taking into account such flows might affect the overall estimates.

The WHO estimates that implementing a portion of the MPOWER tobacco control policies in the 23 low-and middle-income countries that account for 80% of the developing world’s chronic disease burden would cost roughly $800 million/year.19

Questions for further investigation

Our research in this area has been relatively limited, and many important questions remain unanswered by our investigation.

Amongst other topics, further research on this cause might address:

  • How strong is the evidence in favor of the MPOWER interventions? Are some interventions more important to implement than others?
  • What impact has the large influx of funding into tobacco control efforts from the Gates and Bloomberg foundations had?
  • Which of the strategies described above are most likely to be cost-effective?

Our process

We decided to look into tobacco control efforts in low- and middle-income countries because we had heard informally that tobacco was a large and growing cause of mortality globally and that it receives relatively little philanthropic funding. Our investigation mainly consisted of speaking with two individuals with knowledge of the field and some limited desk research.


WHO report on the global tobacco epidemic, 2013Source (archive)
WHO Fact Sheet on Tobacco 2013Source (archive)
The Tobacco Atlas (2012)Source (archive)
MPOWER: A policy package to reverse the tobacco epidemicSource (archive)
Bloomberg Philanthropies 2011Source (archive)
“Bloomberg Philanthropies Pledges $220 Million to Curb Tobacco Use Abroad”Source (archive)
“Michael Bloomberg and Bill Gates Join to Combat Global Tobacco Epidemic”Source (archive)
Gates Foundation Grants DatabaseSource
Callard 2010Source (archive)
Ross and Stoklosa 2011Source
Bollyky and Glassman 2012Source (archive)
WHO Tobacco Free InitiativeSource (archive)
Asaria et al. 2007Source (archive)
  • 1.

    • “Tobacco is the single greatest preventable cause of death in the world today, killing up to half the people who use it. More than one billion people worldwide currently smoke tobacco – about one quarter of adults – and tobacco use currently kills more than five million people worldwide each year. Tobacco use continues to grow in developing countries due to steady population growth along with aggressive tobacco industry marketing efforts.” MPOWER: A policy package to reverse the tobacco epidemic
    • “The tobacco epidemic is one of the biggest public health threats the world has ever faced, killing nearly six million people a year. More than five million of those deaths are the result of direct tobacco use while more than 600 000 are the result of non-smokers being exposed to second-hand smoke. Approximately one person dies every six seconds due to tobacco, accounting for one in 10 adult deaths. Up to half of current users will eventually die of a tobacco-related disease.
      Nearly 80% of the more than one billion smokers worldwide live in low- and middle-income countries, where the burden of tobacco-related illness and death is heaviest.” WHO Fact Sheet on Tobacco 2013

  • 2.

    “The tobacco epidemic is one of the biggest public health threats the world has ever faced, killing nearly six million people a year. More than five million of those deaths are the result of direct tobacco use while more than 600 000 are the result of non-smokers being exposed to second-hand smoke.” WHO Fact Sheet on Tobacco 2013

  • 3.

    “Unchecked, tobacco-related deaths will increase to more than eight million per year by 2030. More than 80% of those deaths will be in low- and middle-income countries.” WHO Fact Sheet on Tobacco 2013

  • 4.

    The Tobacco Atlas (2012) pgs 30-33.

  • 5.

    “The package encourages policy-makers along with the rest of society, including civil society, health-care providers and others, to envision a world free of tobacco use. Furthermore, the package provides the tools to create a world where tobacco use declines by promoting a legal and socio-economic context that favours tobacco-free living. The goal is a world where no child or adult is exposed to tobacco smoke.
    The policy package to reduce global tobacco use requires that proven tobacco policies and interventions be implemented, that they be informed by data from systematic surveys designed to target and refine implementation, and that rigorous monitoring is done to evaluate their impact. Interventions should be implemented with a high level of coverage; partial implementation is generally inadequate for reducing tobacco use in the population.” MPOWER: A policy package to reverse the tobacco epidemic pg 10.

  • 6.

    WHO Fact Sheet on Tobacco 2013

  • 7.

    Most of these approaches are discussed in Bloomberg Philanthropies 2011.

  • 8.

    Bollyky and Glassman 2012.

  • 9.

    • “International efforts led by WHO resulted in rapid entry into force of the WHO Framework Convention on Tobacco Control (WHO FCTC),4 which has 168 signatories and more than 150 Parties. The WHO FCTC provides the principles and context for policy development, planning of interventions and mobilization of political and financial resources for tobacco control. Achievement of tobacco control goals will require coordination among many government agencies, academic institutions, professional associations and civil society organizations at the country level, as well as the coordinated support of international cooperation and development agencies.” MPOWER: A policy package to reverse the tobacco epidemic pg 8.
    • “WHO is committed to fighting the global tobacco epidemic. The WHO Framework Convention on Tobacco Control entered into force in February 2005. Since then, it has become one of the most widely embraced treaties in the history of the United Nations with 176 Parties covering 88% of the world’s population. The WHO Framework Convention is WHO’s most important tobacco control tool and a milestone in the promotion of public health. It is an evidence-based treaty that reaffirms the right of people to the highest standard of health, provides legal dimensions for international health cooperation and sets high standards for compliance.
      In 2008, WHO introduced a practical, cost-effective way to scale up implementation of provisions of the WHO Framework Convention on the ground: MPOWER. Each MPOWER measure corresponds to at least one provision of the WHO Framework Convention on Tobacco Control.” WHO Fact Sheet on Tobacco 2013

  • 10.

    “TFI headquarters is divided into the Director’s Office and three separate units:

    • National Capacity Building, which helps countries to enhance their ability to resist the epidemic of tobacco and implement the WHO Framework Convention on Tobacco Control
    • Comprehensive Information Systems for Tobacco Control, whose responsibilities encompass surveillance of the global tobacco epidemic
    • Tobacco Control Economics, which advises countries on taxation as an instrument of tobacco control policy and other economic policies to control tobacco

    The Director’s Office encompasses administration; communications; tobacco industry monitoring; regulation, legislation and enforcement; grants management; and coordination with external partners and advisers and with other United Nations organs.” WHO Tobacco Free Initiative.

  • 11.

    “Bloomberg Philanthropies, the private foundation of New York City mayor Michael Bloomberg, has pledged $220 million over the next four years to help curb tobacco use in low- and middle-income countries.
    Announced at the World Conference on Tobacco or Health in Singapore, the pledge boosts to $600 million the foundation’s total commitment to fighting tobacco use globally and will support the ongoing activities of the Bloomberg Initiative to Reduce Tobacco Use, which was launched in 2006 to encourage countries around the world to raise tobacco taxes, educate the public about the negative impacts of tobacco use, implement smoke-free laws for public spaces, and urge tobacco users to quit.
    Led by the Campaign for Tobacco-Free Kids, CDC Foundation, theJohns Hopkins Bloomberg School of Public Health, the World Health Organization, and the World Lung Foundation, the initiative will work with the Bill & Melinda Gates Foundation to implement MPOWER policies aimed at reducing death and disability due to tobacco use; foster the development of evidence-based policy change at the country level; and focus on raising the price of tobacco through higher tobacco taxes, which the initiative believes is the single most effective way to reduce tobacco use. In addition, the initiative aims to develop new strategies that build on successes in tobacco control and other strategies such as tobacco industry monitoring; litigation and advocacy support challenging tobacco industry efforts to thwart implementation of MPOWER policies or other related efforts; and providing financial support to governments for the implementation of anti-tobacco initiatives.” “Bloomberg Philanthropies Pledges $220 Million to Curb Tobacco Use Abroad”

  • 12.

    “The Bill & Melinda Gates Foundation announced that it will invest $125 million over five years to fight the tobacco epidemic, including a $24 million grant to the Bloomberg Initiative. In addition to the grant to Bloomberg, the Gates Foundation will support complementary efforts to reduce high rates of tobacco use in countries such as China and India, as well as to help prevent the tobacco epidemic from taking root in Africa.” “Michael Bloomberg and Bill Gates Join to Combat Global Tobacco Epidemic”

  • 13.

    Bloomberg Philanthropies 2011

  • 14.

    Gates Foundation Grants Database

  • 15.

    “Twenty-eight per cent of emerging and developing countries received zero DACT. With few exceptions, countries do not have funding for sustainable tobacco control interventions. Those exceptions are countries with strong civil societies or individuals who advocate for tobacco control, as they seem to attract and effectively utilise the funding (eg, South-East Asia Tobacco Control Alliance led by Bungon Ritthiphakdee, Witold Zatonski in Poland or Yussuf Saloojee in South Africa). This points to the importance of local leadership and strong civil societies. The Bloomberg/Gates initiative recognised this by funding the Global Tobacco Control Leadership Program at Johns Hopkins Bloomberg School of Public Health. OSI funding also supported civil societies. However, even strong local leaders and civil societies have to compete for limited resources, which can undermine the operation of existing and well functioning projects.” Ross and Stoklosa 2011 pg 4.

  • 16.

    “One of the most active supporters of global tobacco control, the Bloomberg Philanthropies, suggested in 2007 that $200 million was spent on international development aid for tobacco control. The basis for their estimate was not stated, but it may have included the annual budget for the functioning of the Framework Convention on Tobacco Control (now $6.5 million), the portion of the WHO budget for tobacco, alcohol, unhealthy diets, physical activity and unsafe sex (the total of which is now $80 million) that is spent on tobacco control, and the estimated annual $62 million investment of the Bloomberg Initiative to Reduce Tobacco Use. Since that estimate was made, a further $25 million annualised donation was announced in 2008 by the Bill and Melinda Gates Foundation, and WHO/TFI produced an estimate of $9.6 million spent on national tobacco control programmes in middle-income and low-income countries. Based on these available estimates, the total available for development assistance for tobacco control is likely no greater than $240 million.” Callard 2010 pg 288.

  • 17.

    Ross and Stoklosa 2011:

    • “During the 1980s and 1990s, small but crucially important funding for tobacco control in low- resource countries became available, primarily thanks to cancer charities based in the USA, UK, Canada, Australia and from the Union for International Cancer Control (UICC).11
      Identified as a priority topic, tobacco control funding was discussed at the 9th World Conference on Tobacco or Health (1994), where the Interna- tional Tobacco Initiative (ITI) was established in order to support research, knowledge management and tobacco control funding. ITI soon became Research for International Tobacco Control (RITC), disbursing about US$100 000 per year towards research, with funding coming primarily from the Canadian government.
      In 2000 the American Cancer Society (ACS) and the Rockefeller Foundation began to invest in global tobacco control, which increased DACT to US$1 million that year, reaching nearly 40 coun- tries. This amount doubled two years later, when George Soros’s Open Society Institute (OSI) invested in tobacco control focusing on advocacy and networking between tobacco control advocates.
      Since then, other organisations, both private and public, have stepped in to support global tobacco control. However, their contributions represent only a small share of their investment portfolio, leaving tobacco control in low-resourced countries underfunded and vulnerable. In 2004 the Rock- efeller Foundation, which funded about 16% of DACT, discontinued its tobacco control funding in order to cope with stock market losses. In turn, the competition for global tobacco control funding intensified and many activities were put on hold.
      A real breakthrough came in 2006, when Michael Bloomberg, encouraged by his success in tobacco control as mayor of New York City, announced his personal commitment of US$125 million to reduce the global burden of tobacco use. In 2008, Bloomberg Philanthropies increased this amount to US$375 million when the Bill and Melinda Gates Foundation joined the effort, investing US$125 million. The combined resources from these two private philanthropies amounted to US$500 million, to be invested from 2007 to 2013. This amount exceeded all previous development assistance for global tobacco control combined.
      The historic shortage of funds and the relatively small number of entities funding global tobacco control motivated an effort to coordinate projects and to collaborate on funding for the larger ones. In 2002 RITC organised meetings to discuss such coordination as well as fundraising to support DACT. The meetings’ participants identified a need to track the flow of global tobacco control funding, and OSI commissioned a feasibility study of such data collection. The study’s results were presented in early 2006 to a group of tobacco control funders that formed the International Tobacco Control Funders Forum. The feedback from this informal group helped to shape the database when it became hosted by ACS in mid-2006.
      In mid-2008, the database was reorganised with the goal of imposing a minimum reporting requirement on the participating agencies, while simultaneously capturing information of interest not only to the tobacco control community, but also to the global public health community. The database is now hosted by the International Tobacco Control Research Program (ITCR) at ACS.” Pgs 1-2.

    • “The database contains information on 956 tobacco control funding disbursements awarded from 1995 to 2010. Out of these, 893 DACT disbursements were awarded to emerging and developing economies between 2000 and 2009. This includes awards directed to individual countries as well as to multina- tional projects, amounting to US$132 million during this time period (or an average of US$0.003 per year per adult). The funding grew from US$1.2 million (or US$0.0003 per adult) in 2000 to US$44.2 million in 2009 (or US$0.011 per adult).
      The field of global tobacco control is characterised by a high degree of collaboration among the funding agencies, since about 39% of awards were classified as collaborative.
      There was almost an equal number of institutional (35%), research (32%) and advocacy (32%) projects funded between 2000 and 2009, but the value of funding favours research (US$47 million) and institutional support (US$43 million) over advocacy (US$36 million). The value distribution reflects the different cost structure of these project types (eg, research projects tend to be more expensive).
      DACT went primarily to specific projects (82% of all awards and about half of money disseminated). About 14% of awards (and one third of the funding) contributed to the general oper- ation of different organisations, and the remaining 4% could not be determined based on this criterion.” Pg 3.

    • “In addition to DACT, local governments and national institu- tions play an important role in funding tobacco control. The WHO data, mostly from 2008, revealed that this funding amounts to US$37 million (about I$73 million) in emerging and developing economies, or about US$0.009 (I$0.018) per adult per year.
      Many countries still rely on DACT rather than on domestic funding, as DACT exceeded domestic public funding in 31 countries in 2008. In Mexico, for example, the government invested slightly more than I$25000 into tobacco control in 2008, but the DACT reached nearly I$2 million in the same year. In Vietnam and Cambodia the DACT in 2008 was more than 10 times higher compared to domestic public funding. Sixty-three countries supported by DACT (59%) reported some domestic public funding. Globally, the 2008 DACT was higher than all domestic public funding combined ($US42 million vs $US37 million).” Pgs 3-4.

    • “The Bloomberg Initiative, launched in 2006 and joined in 2008 by the Bill and Melinda Gates Foundation, changed the global tobacco control funding landscape (figure 2).
      Comparing 2000-2006 and 2007-2009 DACT, the average disbursement increased from US$86 000 to US$389 000 (by 352%). Not only were the awards larger after the launch of the Bloomberg/Gates initiative, they also increased in absolute numbers: during 2007e2009, funding was awarded 139 times per year on average compared to the yearly average of 68 disbursements in the previous period. The Bloomberg/Gates funding shifted focus from research and institutional support to advocacy. In previous years about 20% of disbursements supported advocacy projects (11% of awards’ value), but starting in 2007 as much as 47% of the funding (28% of the awards’ value) has been dedicated to tobacco control advocacy (table 1).
      The average worldwide DACT in emerging and developing economies amounted to US$13 million per year (or US$0.003 per adult) between 2000 and 2009, reaching US$44.2 million in 2009 (or US$0.011 per adult). Additional assistance from domestic public funds reached US$37 million in 2008 (or US $0.009 per adult).
      WHO estimates that low/lower-middle-income and upper- middle-income countries need US$0.10-US$0.23 and US $0.11-US$0.72 per capita, respectively, in order to control the demand for tobacco.16 This estimate clearly contrasts with what is actually disseminated towards tobacco control in any emerging and developing country from DACT and domestic public funding combined. ” Pg 4.

  • 18.

    “Investments in international assistance for tobacco control from both governmental and private sources is much smaller than investments in other identified global health challenges, on both an absolute and relative basis. A recent review of DAH estimated the total ‘financial and in-kind contributions from global health channels that aim to improve health in developing countries’ between 1990 and 2007. This study identified support for HIV/AIDS, tuberculosis and malaria, but did not provide estimates for development assistance for tobacco control. Using the adjusted estimate of DAH for tobacco control provided by the Bloomberg Foundation, discussed above, and combining measures of DAH with estimates of the current and future burden of these diseases shows that DAH for each person living with HIV/AIDS ($111 per year), or tuberculosis ($50) far exceeds the amount provided for each person who smokes ($ 0.25). (Global estimates for malaria cases are not available.) When investments in preventable disease control are measured against predicted deaths in 2030, the funding for malaria ($1189), for tuberculosis ($1127), and HIV/AIDS ($782) again greatly exceed the funding to prevent tobacco-caused disease ($35).” Callard 2010 pg 288.

  • 19.

    Asaria et al. 2007:

    • “We used methods from the WHO Comparative Risk Assessment project to estimate shifts in the distribution of risk factors associated with salt intake and tobacco use, and to model the effects on chronic disease mortality for 23 countries that account for 80% of chronic disease burden in the developing world.” pg 2044.
    • “The WHO Framework Convention on Tobacco Control (FCTC) has proposed a set of policies to reduce demand for tobacco. We selected some of the FCTC’s population-based control measures: increased taxes on tobacco products to reduce smoking prevalence; enforcement of smoke-free workplaces; requirements for FCTC-compliant packaging and labelling of tobacco products combined with public awareness campaigns about the health risks of smoking; and a comprehensive ban on tobacco advertising, promotion, and sponsorship.
      Table 1 shows the estimated change in the real price of tobacco and in smoking prevalence that would result from implementation of these four FCTC policies. Webtables 2 and 3 show a detailed breakdown by country, with relevant demographic and administrative characteristics.
      We did not do the same analyses for the FCTC’s two other population-based policies for reduction of demand for tobacco—regulation of the contents of tobacco products and regulation of tobacco product disclosures (Articles 9 and 10 of the FCTC)—because of information constraints on effect size and resource-need estimates. However, we did include an additional cost estimate for a national household survey every 3 years to ascertain population-wide changes in smoking prevalence, since this underpins many of the modelled intervention strategies.” pg 2045.

    • Webtable 7 reports that the total cost of the included smoking interventions is $803,755,716 per year (for 2005).