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May 2014 | Issue 56 Regional | Health Without intervention, cigarette smoking will eventually kill about 267 million current and future smokers in the People’s Republic of China, India, the Philippines, Thailand, and Viet Nam. In these five Asian countries, increasing tobacco taxes is a pro-poor measure that can reduce the number of smokers and smoking-related deaths, and generate substantial new revenues. Use of these new revenues to finance health services for the poor can increase impacts on both poverty and health. How Tobacco Taxes Can Expand Fiscal Space and Benefit the Poor ASIA’S DOUBLE HEALTH BURDEN Infectious diseases have generally plagued poorer countries while noncommunicable diseases have affected richer nations. 1 In Asia— where two-thirds of the global population reside and half of the world’s poor are found—this scenario is changing. More and more people are suffering from noncommunicable diseases, often as a result of unhealthy lifestyles. 2 Noncommunicable diseases progress more slowly, compared with many communicable diseases which tend to affect people quickly. This creates complex health needs that are expensive to treat and can overwhelm already stressed health care systems. The problem is predicted to become more acute with the aging of populations. While its noncommunicable diseases are on the rise, Asia still faces an unfinished agenda of communicable diseases—from water- borne illnesses to malaria. With urban populations likely to increase by 20%–25% by 2050, overcrowding in big cities could also inflate the risk of infectious disease transmission. Increased production of animals for food also has inherent risks as many infectious diseases, such as influenza, are passed from animals to humans. Hence, Asia’s developing economies and health authorities confront a growing, double burden of ever-present and re-emerging infectious diseases—with possible unexpected outbreaks of new ones—as well as an explosion of noncommunicable diseases. 3 Public health experts advocate that the war needs to be waged on two fronts: public education and policies that encourage healthy eating and healthier lifestyles. Raising tobacco taxes, for one, is a win–win measure. THE SCOURGE OF SMOKING A Global Health Hazard. Smoking is a global health hazard and a huge challenge. According to the World Health Organization, an estimated 5–6 million deaths were caused by tobacco use in 2010. Mortality is projected to nearly double by 2030. 4 About 1 billion people will be killed from smoking this century unless smoking cessation significantly increases among adults. Cessation substantially reduces the risks of smoking. Those who quit before the age of 40 can achieve death rates close to nonsmokers. 5 Aggressive Tobacco Marketing. While cessation has become very common in high-income countries (e.g., there are more ex-smokers than current smokers in the United Kingdom), it is not widespread in Asian countries. Out of the world’s 1.2 billion smokers, two-thirds live in just 15 countries, 6 of which—the People’s Republic of China (PRC), India, Indonesia, the Philippines, Thailand, and Viet Nam— are in Asia. 6 This is partly due to the aggressive marketing done by tobacco companies. 7 The industry actively markets cigarettes and ___________________ 1 The main noncommunicable diseases are cardiovascular diseases, diabetes, mental illness, chronic respiratory diseases, and cancer. These are usually caused by unbalanced diets, physical inactivity, alcohol or drug abuse, stress, inadequate sleep, and tobacco use. The main infectious diseases—caused by bacteria, fungi, parasites, and viruses—are lower respiratory infections, HIV/AIDS, diarrheal diseases, tuberculosis, and malaria. 2 Diabetes, obesity, and excess weight from energy-dense, big-portion, and fast-food meals have become worrisome in Asia. See the International Diabetes Foundation’s 2014 IDF Diabetes Atlas at www.idf.org/diabetesatlas 3 H5N1 (avian influenza), a new regional pandemic, struck as recently as 2009. 4 Most mortality among smokers is due to neoplastic, vascular, respiratory, and other diseases that can be caused by smoking. World Health Organization. 2011. MPOWER: A Policy Package to Reverse the Tobacco Epidemic. Geneva. 5 Prabhat Jha. 2009. Avoidance of Worldwide Cancer Mortality and Total Mortality from Smoking. Nature Reviews: Cancer. Vol. 9; pp. 655–664. 6 Overall, 80% of the world’s smokers are from developing countries, with a commensurate ratio of deaths occurring there. 7 The Federal Trade Commission says cigarettes are still among the most heavily advertised and promoted products in the world, with spending reaching $8.6 billion annually in the United States alone. The Southeast Asia Tobacco Control Alliance notes that some governments in developing nations even rely on finance from tobacco companies—under "corporate social responsibility" programs—to cover costs of public services, including schools. See Southeast Asia Tobacco Control Alliance. 2014. Tobacco Industry Interference Index. Available: www.seatca.org/dmdocuments/SEATCA-TII%20Index%20Report.pdf Increasing cigarette taxes can significantly reduce the number of current and future smokers. Photo by ADB Photo Library Knowledge Showcases

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Without intervention, cigarette smoking could kill about 267 million smokers in the People’s Republic of China, India, the Philippines, Thailand, and Viet Nam. Raising tobacco taxes in these countries can deter smoking, reduce the number of smoking-related deaths, and generate revenues to help meet healthcare costs for the poor.

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Page 1: How Tobacco Taxes Can Expand Fiscal Space and Benefit the Poor

May 2014 | Issue 56 Regional | Health

• Withoutintervention,cigarettesmokingwilleventuallykillabout267millioncurrentandfuturesmokersinthePeople’sRepublicofChina,India,thePhilippines,Thailand,andVietNam.

• InthesefiveAsiancountries,increasingtobaccotaxesisapro-poormeasurethatcanreducethenumberofsmokersandsmoking-relateddeaths,andgeneratesubstantialnewrevenues.

• Useofthesenewrevenuestofinancehealthservicesforthepoorcanincreaseimpactsonbothpovertyandhealth.

How Tobacco Taxes Can Expand Fiscal Space and Benefit the Poor

ASIA’S DOUBLE HEALTH BURDEN

Infectiousdiseaseshavegenerallyplaguedpoorercountrieswhilenoncommunicablediseaseshaveaffectedrichernations.1InAsia—wheretwo-thirdsoftheglobalpopulationresideandhalfoftheworld’spoorarefound—thisscenarioischanging.Moreandmorepeoplearesufferingfromnoncommunicablediseases,oftenasaresultofunhealthylifestyles.2

Noncommunicablediseasesprogressmoreslowly,comparedwithmanycommunicablediseaseswhichtendtoaffectpeoplequickly.Thiscreatescomplexhealthneedsthatareexpensivetotreatandcanoverwhelmalreadystressedhealthcaresystems.Theproblemispredictedtobecomemoreacutewiththeagingofpopulations.

Whileitsnoncommunicablediseasesareontherise,Asiastillfacesanunfinishedagendaofcommunicablediseases—fromwater-borneillnessestomalaria.Withurbanpopulationslikelytoincreaseby20%–25%by2050,overcrowdinginbigcitiescouldalsoinflatetheriskofinfectiousdiseasetransmission.Increasedproductionofanimalsforfoodalsohasinherentrisksasmanyinfectiousdiseases,suchasinfluenza,arepassedfromanimalstohumans.

Hence,Asia’sdevelopingeconomiesandhealthauthoritiesconfrontagrowing,doubleburdenofever-presentandre-emerginginfectiousdiseases—withpossibleunexpectedoutbreaksofnewones—aswellasanexplosionofnoncommunicablediseases.3Publichealthexpertsadvocatethatthewarneedstobewagedontwofronts:publiceducationandpoliciesthatencouragehealthyeatingandhealthierlifestyles.Raisingtobaccotaxes,forone,isawin–winmeasure.

THE SCOURGE OF SMOKING

A Global Health Hazard.Smokingisaglobalhealthhazardandahugechallenge.AccordingtotheWorldHealthOrganization,anestimated5–6milliondeathswerecausedbytobaccousein2010.Mortalityisprojectedtonearlydoubleby2030.4About1billionpeoplewillbekilledfromsmokingthiscenturyunless

smokingcessationsignificantlyincreasesamongadults.Cessationsubstantiallyreducestherisksofsmoking.Thosewhoquitbeforetheageof40canachievedeathratesclosetononsmokers.5

Aggressive Tobacco Marketing.Whilecessationhasbecomeverycommoninhigh-incomecountries(e.g.,therearemoreex-smokersthancurrentsmokersintheUnitedKingdom),itisnotwidespreadinAsiancountries.Outoftheworld’s1.2billionsmokers,two-thirdsliveinjust15countries,6ofwhich—thePeople’sRepublicofChina(PRC),India,Indonesia,thePhilippines,Thailand,andVietNam—areinAsia.6Thisispartlyduetotheaggressivemarketingdonebytobaccocompanies.7Theindustryactivelymarketscigarettesand

___________________1Themainnoncommunicablediseasesarecardiovasculardiseases,diabetes,mentalillness,chronicrespiratorydiseases,andcancer.Theseareusuallycausedbyunbalanceddiets,physicalinactivity,alcoholordrugabuse,stress,inadequatesleep,andtobaccouse.Themaininfectiousdiseases—causedbybacteria,fungi,parasites,andviruses—arelowerrespiratoryinfections,HIV/AIDS,diarrhealdiseases,tuberculosis,andmalaria.2Diabetes,obesity,andexcessweightfromenergy-dense,big-portion,andfast-foodmealshavebecomeworrisomeinAsia.SeetheInternationalDiabetesFoundation’s2014IDF Diabetes Atlas atwww.idf.org/diabetesatlas3H5N1(avianinfluenza),anewregionalpandemic,struckasrecentlyas2009.4Mostmortalityamongsmokersisduetoneoplastic,vascular,respiratory,andotherdiseasesthatcanbecausedbysmoking.WorldHealthOrganization.2011.MPOWER:A Policy Package to Reverse the Tobacco Epidemic. Geneva.5PrabhatJha.2009.AvoidanceofWorldwideCancerMortalityandTotalMortalityfromSmoking.Nature Reviews:Cancer.Vol.9;pp.655–664.

6Overall,80%oftheworld’ssmokersarefromdevelopingcountries,withacommensurateratioofdeathsoccurringthere.7TheFederalTradeCommissionsayscigarettesarestillamongthemostheavilyadvertisedandpromotedproductsintheworld,withspendingreaching$8.6billionannuallyintheUnitedStatesalone.TheSoutheastAsiaTobaccoControlAlliancenotesthatsomegovernmentsindevelopingnationsevenrelyonfinancefromtobaccocompanies—under"corporatesocialresponsibility"programs—tocovercostsofpublicservices,includingschools.SeeSoutheastAsiaTobaccoControlAlliance.2014.Tobacco Industry Interference Index.Available:www.seatca.org/dmdocuments/SEATCA-TII%20Index%20Report.pdf

Increasingcigarettetaxescansignificantlyreducethenumberofcurrentandfuturesmokers.

PhotobyADB Photo Library

Without intervention, cigarette smoking will eventually

HighlightsKnowledge Showcases

Page 2: How Tobacco Taxes Can Expand Fiscal Space and Benefit the Poor

©AsianDevelopmentBank PublicationStockNo.ARM146554-2

KNOWLEDGE CONTRIBUTORS

TheKnowledgeShowcasesSeries,aproductoftheKnowledgeSharingandServicesCenter,highlightsgoodpracticesandinnovativeideasfromADBtechnicalassistanceandotheroperationstopromotefurtherdiscussionandresearch.

www.adb.org/knowledgeshowcaseswww.adbknowledgeshowcases.org

TheAsianDevelopmentBank(ADB)isdedicatedtoreducingpovertyintheAsiaandPacificregion.

Theviewsexpressedinthispublicationarethoseoftheauthor(s)anddonotnecessarilyreflecttheviewsandpoliciesofADBoritsBoardofGovernorsorthegovernmentstheyrepresent.

Patricia Moser([email protected])isaleadhealthspecialistinADB’sRegionalandSustainableDevelopmentDepartment.

fightspublichealthpolicies(throughtrade,judicial,andlegislativeactions)topreventbansoncigaretteadvertising,taxincreases,andothereffectiveanti-tobaccomeasures.

Tackling the Scourge through Policies.However,allsixcountriesarepopulous,growingeconomies,wherecigarettesmokingisontherise.Afailuretoholddownthescourgeofsmokingwillhavemajorpublichealth—andhealthfinancing—implicationsforbothcurrentandfuturegenerations.Fortuitously,tacklingtheproblemoftobaccodoesnotdependonscientistsfindinganelusivevaccine:legislationthatmakescigarettespriciercandirectlyreducetobaccouse,especiallyamongpoorandyoungpeople.Policiessuchasbansonsmokinginpublicplaceshelptoo,andareneededasafullresponsetosustainreducedtobaccouse.8

TOBACCO TAXES: A WIN–WIN MEASURE FOR FISCAL SPACE AND HEALTH

In2012,theAsianDevelopmentBank(ADB)investigatedhowtobaccotaxesmightreduceconsumptionandsavelivesinfiveoftheAsianhigh-burdencountries.ThestudyfoundthatforthePRC,India,thePhilippines,Thailand,andVietNam,increasesincigaretteprices(intherangeof25%–100%)wouldeffectivelyreducethenumberofsmokersandthenumberofsmoking-relateddeaths.Additionally,theincreaseswouldgeneratesubstantialnewrevenues,atimelywindfallsinceportionsofthepopulationsofthesecountriesreceivefreeornearlyfreehealthcare,thecostsofwhichmustbemet.

Table: Percentage of Population with Free or Nearly Free Health Care—Selected Countries

Source:ADB.2011.BurdenofHealthCosts.InWho Will Pay for Asia’s Double Burden? Innovative Financing is Needed to Address an Unprecedented Burden of Communicable and Noncommunicable Diseases.Manila.www.adb.org/publications/who-will-pay-asias-double-burden-innovative-financing-needed-address-unprecedented-burd

Reduced Cigarette Consumption. Inthefivecountriescovered,increasingcigarettepricesby50%,whichcorrespondstoataxincreaseofabout70%–122%,wouldreducethenumberofcurrentandfuturesmokersbynearly67millionandreducetobaccodeathsby27million.9

Increased Revenues. A50%increaseincigarettepriceswillalso

generate$24billioninadditionalrevenueannually.Thiswouldmeana143%–178%increaseovereachcountry’scurrentcigarettetaxrevenue.Therevenueincrease,or“fiscalspace,”wouldaverage0.30%ofgrossdomesticproduct,withawiderangeof0.07%–2.52%.

A Pro-poor Measure. Thepoorestsocioeconomicgroupsineachcountrywillcarryonlyasmallpartoftheextrataxburden.Inreturn,theywillreapasubstantialproportionofthehealthbenefitsofreducedsmoking.Theratioofhealthbenefitsaccruedtothepoortotheextrataxesbornebythepoorwouldrangefrom1.4to9.5.

Clearly,largeincreasesinthetobaccotaxinallfivecountriesareunusuallyattractiveforpublichealthandpublicfinance,andarepro-poorintheirhealthbenefits.

Related Links• ADB.2011.Who Will Pay for Asia’s Double Burden? Innovative Finaning is Need-

ed to Address an Unprecedented Burden of Communicable and Noncommunicable Diseases.Manila.Available:www.adb.org/publications/who-will-pay-asias-double-burden-innovative-financing-needed-address-unprecedented-burd

• ADB.2012.Tobacco Taxes:A Win–Win Measure for Fiscal Space and Health.Ma-nila.Available:www.adb.org/publications/tobacco-taxes-win-win-measure-fiscal-space-and-health

• ADB.2014.AsianDevelopmentOutlook.www.adb.org/publications/series/asian-development-outlook

Olivier Serrat ([email protected])isaprincipalknowledgemanagementspecialistinADB’sRegionalandSustainableDevelopmentDepartment.

___________________

8Otherpoliciesincludecomprehensivebansontobaccoadvertisingandpromotion;betterpublicinformation,forexamplebymeansofmassmediacounteradvertisingandprominentlabelsoncigarettepacksaboutthehealthrisksoftobaccouseandthebenefitsofquitting;andhelpforsmokerswhowanttostopsmoking.9Thestudyreckonedthatintheabsenceofintervention,smokingwouldeventuallykillabout267millioncurrentandfuturecigarettesmokerswhoarealivetodayinthefivecountries.

ImageusedfortheWorldNoTobaccoDay,31May.Source:WorldHealthOrganizationwww.who.int/campaigns/no-tobacco-day/2014/poster/en/

China, The People' s Republic of 50± 70India 30± 40Indonesia 30± 40Philippines 30± 40Thailand >70Viet Nam 20± 30


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