Stopping cancer: don’t tell people to quit smoking, ban it

Efforts to prevent chronic diseases such as cancer, diabetes and asthma and heart disease are increasingly turning to the developing world, where 80% of the non-communicable diseases (NCDs) burden lies.

The issue is no longer whether the problem exists – it undeniably does, with health, economic, and development consequences – but instead what strategies are advocated to prevent the 35 million lives lost each year to NCDs, and the $47 trillion in costs projected by 2030.

Woman smoking in Bangladesh Government interventions work better than public health ads. Photograph: AFP/Getty

To address this it’s tempting for governments to start campaigns about quitting smoking, eating healthily, drinking less alcohol, exercising more, and taking medicines like the polypill.

However, narrow strategies relying upon individual behavioural change are less effective in the long run and deflect from more effective population-wide government policies including regulation of industry.

Population level strategies, in contrast, focus on broader change through systemic policies such as restrictions on tobacco marketing, regulation to reduce trans fats in food, minimum pricing rules for alcohol, and urban planning to increase recreational green space and cycling lanes.

Developing countries seem particularly vulnerable to a misguided focus on narrow, individual strategies. Individualised campaigns are far cheaper, easier to mount, and require no confrontation of powerful industries and manufacturers.

Evidence grows that population-wide policy interventions such as traffic light nutrition labelling and junk food taxes are more cost-effective than weight loss drugs or exercise campaigns. The removal of subsidies on coal, gasoline, and diesel – which in developing countries often generate income that exceeds what is spent on health care and education – can both reduce exposure to disease-causing pollutants and free up funds to spend on public services. Regulating the amount of salt in processed foods can reduce the occurrence of heart disease.

Too often, attempts by developing countries to apply NCDs strategies are actually expectations of individual behaviour change. For example, Bangladesh’s current strategic plan for NCDs developed with WHO emphasises regular physical activity as a way to avoid 80% of cardiovascular disease or stroke.

But campaigns such as these fail to acknowledge the declining opportunities for movement that exist in many settings across the world due to urbanisation, desk-bound work and motorised transport. In Dhaka, like many mega-cities, NCD rates are escalating at the same time as massive migration to the city, where populations are becoming more sedentary with limited options for physical activity in the polluted, congested, crowded urban space.

Similarly, “eat better” directives ignore how food and beverage companies’ activities strongly shape the choices individuals make: unhealthy consumption is influenced heavily by the fact that these products are often cheap, available, convenient, and made desirable by savvy marketing.

Bangladesh’s current plan acknowledges unfettered activity of food and beverage companies as a source of the problem, but its strategies are clearly about health promotion for lifestyle change and access to health care – both squarely reliant on individual behaviour.

Quit smoking campaigns, even when communicated to the broad public, reinforce tobacco exposure as an individual choice alone. But this ignores that smoking is influenced by social norms, health beliefs, a person’s economic and employment circumstances and tobacco industry marketing. In the developing world this is especially narrow: tobacco exposure may be secondary in some environments to indoor air pollution as the major risk factor, and the incursion and marketing by tobacco companies is aggressive and often unregulated.

In fact, a focus on individual behaviour provides cover for the tobacco, food, beverage, and alcohol industries as they expand into developing countries: they are uninterested in having their production and marketing of products curtailed through regulation or restrictions, nor the profits that wide consumption ensures. And since industry has previously lobbied against population-level strategies it can be expected they will continue to do so.

The activities of industry in developing countries amplifies the challenges for governments to enact effective population-wide action. The private sector is highly unregulated in many poor countries and transnational companies are exploiting emerging global markets, allowing the rapid spread of cheap, highly processed and unhealthy food, as well as tobacco. While Bangladesh was the first nation to ratify the Framework Convention on Tobacco Control in 2004 and adopted a Smoking and Tobacco Products Usage/Control Act in 2005, it has proved difficult to implement cigarette taxes, public smoking bans, and advertising restrictions – smoking rates remain the highest in South Asia.

As Bangladesh and other countries in south-east Asia upgrade their NCDs action plans, they must translate the acknowledgement of a ‘whole of society approach’ into genuine legislative and regulatory policies that can stem the growth of these diseases, not just expect individuals to change their habits.

-The Guardian