London School of Hygiene & Tropical Medicine

Those working in tobacco control have much to celebrate. Rates of tobacco use globally have fallen. But the world’s population has grown, so today there are still 1.3 billion tobacco users, most of them wanting to quit.

Yet, nicotine is addictive and, despite the tobacco industry’s efforts to portray itself as being part of the solution, it continues to actively promote nicotine and tobacco in an ever increasing variety of forms. One thing is clear – the tobacco industry wants to replace its users and maximize its profit by sustaining the use of these products. 

A new report from the World Health Organization tells us what we should be investing in helping people quit tobacco and reduce the number of people hooked on nicotine. The report sets out a series of proven cessation measures that help people quit successfully and reduce the enormous avoidable burden of tobacco-related disease.

Before we look at what it says, we should reflect on what we have learned during the COVID-19 pandemic. From a public health perspective, three things stand out. First, what matters most when we measure a country’s progress is the health of its citizens. Even if our primary focus is on the economy, we have seen that if threats to health are ignored, it would be at our peril. And tobacco-related disease is an obvious threat, disabling or killing large numbers of people in middle age when they still have much to contribute to the society.

Second, when potential threats to health occur, they mercilessly exploit established inequalities. In all countries, those who suffered most in the pandemic were those whose health was worst going into it, with smoking being one of the leading drivers of those inequalities.

Third, governments make a difference. Political leaders who acted in a timely and decisive way saved hundreds of thousands of lives that would have been lost if they had adopted the policies of others who failed to act rapidly. In the same way, some governments have created the conditions that had brought smoking rates to very low levels while others have failed.

These considerations are shaping the way that we design the post pandemic world.

A series of panels and commissions, including the pan European Commission on Health and Sustainable Development in which I served, have called for new structures that bring together those concerned with health and finance, at national, regional, and global levels.

These calls were taken up at the recent G20 meeting when a task force was established to explore the potential for a future Global Health and Finance Board, modelled on the Financial Stability Board created in the aftermath of the financial crisis.

Its role would be to free up money when needed in a crisis but, as importantly, to ensure that governments did everything possible to minimise the risk of a crisis occurring, including measures to promote and protect the health of their populations.

Of course, this is something they have already committed to in the Sustainable Development Goals (SDGs), but it has been too easy to allow this commitment to fall down the list of priorities. So, if the world’s governments are serious about health, we can expect tobacco control to feature prominently, although given their past actions, we can equally expect the tobacco industry to do everything they can to prevent it being considered.

The Global Investment Case for Tobacco Cessation explains why this must not be allowed to happen and lists six measures that can make a real difference.

Three population-level interventions provide encouragement and support for those trying to quit tobacco. These are: brief advice every time a smoker consults with a health worker, a national toll-free quit line, and cessation support delivered to mobile phones. On the other hand, three are pharmacological. These are: nicotine replacement therapy, and two medicines - Bupropion and Varenicline, which have recently been included in the WHO List of Essential Medicines. They reduce craving for nicotine and decrease the pleasurable effects of cigarettes. Although all of these are proven to work, less than one third of the world’s smokers, mainly those in rich countries, can access them. 

The inevitable question is how much it would cost to scale this up. The answer is: not much.

WHO estimates that this could be done for an additional investment of $US 1.68 per person per year worldwide over this decade. This could have enormous impact, supporting 152 million people to quit and saving almost three million lives by 2030, further increasing to a total of 16 million lives saved by the time those quitting reach 65 years of age.

But as importantly, for those in finance ministries, the estimated return on investment would be US$ 7.50 for every dollar invested. At a time when the world’s governments must find the means to invest in the green revolution necessary to save our species, every little helps.