• Backlash to the apparent backtrack on global tobacco control

    Two life experiences brought me to blogging and health policy advocacy over the past decade.

    One has been the nine-year experience helping to care for my brother-in-law Vincent, who experiences intellectual disabilities connected with fragile X syndrome. I’ve written about this here many times.

    The second set of experiences were the events that precipitated the joys and heartaches of this caregiving experience: The harrowing deaths of my wife’s parents Janice and Gregory Perrone. Both were smokers, and both died far too young from lung cancer.

    The Obama administration has accumulated a strong, readily-overlooked record in domestic tobacco control. Tobacco taxes—a key tool to discourage teen smoking and to induce smokers to quit—have been increased. The FDA has tightened regulation of diverse tobacco products. The Affordable Care Act expands access to evidence-based smoking cessation treatment. Overall, the administration’s tobacco control efforts may well save more lives than the expansion of health insurance coverage to millions of the uninsured.

    This strong track record sets a high bar for the Obama administration’s global tobacco control efforts—which makes its apparent retreat in global trade negotiations especially noteworthy. As Julian Pecquet describes at the Hill

    The Obama administration is backing away from plans to protect U.S. tobacco-control measures from legal challenges under a pending Pacific trade deal, earning the wrath of public-health groups.

    The Office of the U.S. Trade Representative (USTR) last year suggested creating a “safe harbor” that would have it difficult for cigarette companies to undermine domestic anti-smoking efforts under the proposed Trans-Pacific Partnership (TPP). Instead, critics say, the USTR has opted for weaker language that simply restates existing international trade policy that recognizes countries’ authority to enact health and safety measures.

    This isn’t the worst thing in the world; nor is it particularly surprising in light of past U.S. trade policies. Lydia DePillis describes the rather shameful history in a nice Wonkblog piece. As she points out, both policymakers and an array of American industries have good reasons and bad to seek narrow public health exceptions to free trade agreements. Once a tobacco precedent is set, fast food could easily come next. There’s little doubt that many nations (including the United States) would seek to use such exceptions to protect domestic firms from foreign competitors.

    Still, the Obama administration’s retreat remains disappointing. I’m glad that a coalition of normally-Obama-friendly public health organizations did their best to clobber the administration over it:

    Previously, USTR in May 2012 had announced it would propose new language to the TPP that would have created a “safe harbor” protecting national tobacco control measures from being challenged under the agreement. USTR stated at the time that the proposal would “explicitly recognize the unique status of tobacco products from a health and regulatory perspective….”

    Instead, USTR is abandoning this proposal and has announced that it will offer language explicitly reaffirming that tobacco control measures are included in a provision of the General Agreement on Tariffs and Trade (GATT) that recognizes nations’ authority to enact health and safety measures. This is the first time tobacco would be singled out as being included in the public health exception to the GATT. However, this language is far weaker than USTR’s original proposal, would not cover lawsuits initiated by tobacco companies and would not provide nations that adopt strong tobacco control measures with the protection they need from tobacco industry challenges.

    Mayor Bloomberg, among others, has added to this chorus, too.

    He’s right to be angry, because there’s no more important public health issue in the world. More than 400,000 Americans die every year of tobacco-related causes. Around the world, between five and six million people die from smoking every year. About half of these deaths will occur among adults of working age.

    These huge numbers are almost almost unfathomable. It is as if the combined populations of Chicago and Houston simply disappeared this year. Then San Diego and Seattle were wiped off the map next year, and so on, roughly forever.

    Tobacco misuse remains the leading preventable cause of death and morbidity around the world. Smoking-related deaths are declining in the wealthiest countries, but the situation is much more serious in middle- and low-income countries. The best projections suggest that one billion people may die of smoking-related causes over the next century.

    Rising incomes aggravate the problem.  People have the disposable income to buy cigarettes. The growth of open trade—for so many reasons an incredibly beneficial development—also creates new challenges. It brings cheaper and more-effectively-marketed tobacco products where they have not been sold at the same scale before.

    The United States government has a mixed record in all of this. Our trade representatives have fought to pry open cigarette markets in Asia and elsewhere for American manufacturers. In many cases, American manufacturers were fighting protectionist barriers to reach consumers served by rival firms or by sleepy public monopolies. In other cases, the industry was trying to override regulatory measures of great public health value.

    In both cases, the public health impact of some U.S. government actions was to cause widespread harm. And the problem is more basic than the need to get a few details right. Simply put, trade-liberalizing measures that lower cigarette prices or that induce more vigorous advertising and marketing increase population smoking prevalence, and thus tobacco-related deaths. A growing academic literature underscores this basic point.

    This episode reminds us of something else, too. Open trade is extremely valuable for developing economies, and for the United States. Yet markets don’t always or automatically promote the public good. Some markets–such as the one for cigarettes–cause great harm.

    It’s helpful to start with some moral and practical clarity. As the USTR rightly acknowledges, tobacco is no ordinary product. It causes premature death and serious illness among hundreds of millions of the people who use it.

    This is no ordinary industry, either.  A USTR spokesperson comments: “As we do for other products, we will continue to press for the elimination of tariffs on tobacco, which, by their very nature, discriminate against foreign suppliers.”

    I sympathize with this statement as an abstract matter of trade policy. In an ideal world, every country would implement stringent public health measures applied equally to domestic and foreign firms. In our actual world, I hope our government puts tobacco tariffs on the absolute bottom of the pile. Surely there is some shoelace maker or victim of software piracy more deserving of help.

    The tobacco industry deserves the coolest of civilities, the most stringent of regulations from public authorities. It merits no particular help from our nation’s diplomats and trade representatives, either.

    This episode being a matter of public health, I expect it to fade from the headlines. Politically speaking, it rates about a “1” out of “10” on the Syria/Benghazi/NSA/VMA scale. Still, it’s gratifying to see the Obama administration taking some political heat from its usual allies when it seems to waver on important matters of life and health.

    Some in the administrative might not even mind to see it. As Franklin Roosevelt was once reputed to have said: “I agree with you, I want to do it, now make me do it.” That’s not a bad guide in public health.

    @haroldpollack

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    • It seems to me that millions suffer serious illness and die on account of sex. Does Obama have a plan to tax sex?

    • One thing I’d like to see addressed somehow (but have no idea how to do it): people with serious psychiatric illnesses who smoke cigarettes. My evidence is anecdotal, but as a social worker I find the majority of clients to be smokers; the more serious the illness, it has seemed to me, the more likely they are to smoke.

      Often, my clients aren’t able to think long-term enough to worry about the health considerations; even more often, they say that they can’t drink because of their meds, and they can’t do (fill-in-the-blank leisure activity) because of their illnesses…so “it’s my only real pleasure.” Some research indicates that there is actual short-term relief from their psychiatric symptoms; meanwhile, cognitive-behavioral smoking cessation programs don’t seem to work well for this population (I need to look up the comparative effectiveness, vs. a “normal” population, if those statistics are available), and the meds designed to help often have harmful interactions with other medications they might be on.

      Meanwhile, the high rate of smoking-related illnesses is one of the major reasons that people diagnosed with schizophrenia are likely to die much younger than otherwise-comparable members of their cohort. This may not have a measurable effect on the population at large, but it’s a group whose needs should be addressed.