A Thai Buddhist monk in front of an anti-smoking billboard displayed at a Zoo in Bangkok. Photo: AFP/Pornchai Kitiwongsak
A Thai Buddhist monk in front of an anti-smoking billboard displayed at a zoo in Bangkok. Photo: AFP / Pornchai Kitiwongsak

Dr Derek Yach, an expert on global health and an anti-smoking advocate for more than 30 years, is the president of the Foundation for a Smoke-Free World. Throughout his career, he has supported and led smoking-cessation research and policy development, and has been calling for a greater emphasis on harm reduction since as early as 2005.

Dr Derek Yach.

Dr Yach is a former World Health Organization (WHO) cabinet director and executive director for noncommunicable diseases and mental health, where he was deeply involved with the development of the Framework Convention on Tobacco Control (FCTC).

He is also the former chief health officer of the Vitality Group, executive director of the Vitality Institute, senior vice-president of global health and agriculture policy at PepsiCo, director of global health at the Rockefeller Foundation, and a professor of global health at Yale University.

He has authored or co-authored more than 250 peer-reviewed articles on global health and has served on several advisory boards, including the World Economic Forum, Cornerstone Capital and the Wellcome Trust. From 2007 to 2016, he served on the program advisory committee of the Clinton Global Initiative.

Yach is a native of South Africa and has an honorary Doctor of Science degree from Georgetown University, a medical degree from the University of Cape Town, Bachelor of Science (Hons) in epidemiology from the University of Stellenbosch, and a Master of Public Health from the Johns Hopkins Bloomberg School of Public Health.

Yach spoke to Asia Times on the tobacco-control strategies needed to end smoking globally. Excerpts of that interview follow.

Sachi Satapathy: In one of your recent research papers, “Accelerating an End to Smoking: A Call to Action on the Eve of the FCTC’s Ninth Session of the Conference of the Parties (COP9)” published by Emerald Publishingyou projected that even if the full suite of FCTC recommendations is implemented, annual smoking-related deaths will rise from the current rate of 7 million to reach 10 million in the early 2030s. Will you please explain the basis of this argument?

Derek Yach: Decades of cohort studies demonstrate a lag between the point at which one starts smoking and the onset of symptoms from diseases it causes.

This lag can range from a few years (for example in the case of respiratory symptoms) to several decades (for example for the development of lung cancer or COPD [chronic obstructive pulmonary disease]). Similarly, there exists a delay between the time that an individual quits smoking and the associated reduction in risk for these conditions: Risk of heart attack decreases within a few years and the risk of cancers falls over the course of decades.

For other conditions, smokers will have a life-long excess risk compared [with] never-smokers, even after they quit. At a population level, there is a corresponding lag. Decreases in global smoking rates will take time to manifest as substantial reductions in death statistics.

SS: Having spent decades in global health, including at the WHO as executive director and being a key proponent of the FCTC since its inception, what according to you are key areas where the FCTC needs modernization, including areas of deep neglect requiring urgent attention and revision?

DY: A decade after leaving WHO I published a review of the development of the FCTC, which addresses this question. Specifically, I note that improving the FCTC requires: tackling complacency, building capacity for science in developing countries, giving greater attention to women and girls, and considering the role of tobacco harm reduction. These views remain valid.

More recently I took a closer look at progress toward the implementation of the FCTC, considering both the WHO’s own review, as well as those of independent researchers. Following this analysis, I identified four broad areas of needed improvement in the treaty:

  • The FCTC must be modernized to leverage innovations in harm reduction.
  • The public health community must accelerate actions to end smoking. This requires: improvement in cessation strategies, a stronger focus on women, and evidence-based taxation policies.
  • Relevant parties must develop new initiatives to address outstanding needs. This includes programs that consider alternative livelihoods for economies dependent on tobacco farming; address funding gaps for critical initiatives; and fill national and global research gaps.
  • Implementation of the FCTC requires a shift in philosophy. In fact, the tobacco-control community at large would benefit from a shift that promotes multi-sectoral engagement, increased transparency, and respectful dialogue.

In the aftermath of Covid-19 there is a greater imperative to stamp out smoking, which is the most preventable cause of death and disease in the world. However, I fear that the prioritization of pandemic preparedness and management may well usurp attention from the smoking epidemic.

 SS: Eighty percent of the 1.1 billion smokers worldwide live in low- and middle-income countries (LMICs). What would be your key recommendations to these resource-constrained countries to help them come out of this crisis?

DY: The history of tobacco control teaches us that medical doctors can play an influential role in curbing tobacco use in their communities. When doctors take the lead – by addressing tobacco use with patients, quitting smoking themselves, and advocating for policy change – sustained action follows.

Physicians were, in fact, key to progress in the USA and OECD countries, where smoking rates have dropped steadily over the decades. In these countries, doctors’ smoking rates dropped and, within a decade, smoking rates fell in the general population. In many major LMICs, physician smoking rates remain extremely high. Correspondingly, doctors’  “voice” and advocacy is weak. Until this changes, progress will be slow.

In addition, I should note that smoking rates tend to decline when countries adopt science-based policies. In such countries, epidemiological, economic, and public perception studies accomplish two things: (1) provide an objective basis for policymakers to act; and (2) build a cadre of informed researchers and policymakers who know how to use science.

In a recent paper, Navin Kumar shows that research capacity in LMICs is weak. This must change if these countries are to tackle smoking in a sustainable way. 

SS: What, according to you, are the major reasons for not achieving good progress in mainstreaming of gender factors into tobacco control, resulting in negative health and economic consequences? Will you please suggest measures to address this gap?

DY: Historically, global tobacco-control efforts have been gender-blind – meaning, they fail to consider needs specific to women or strategies that may be particularly useful in reducing their smoking rates. As a result, global smoking rates among men are declining, but rates among women have yet to peak and are set to increase in many countries – a point recently highlighted in a paper by Alexandra Solomon.

While the FCTC mentions the need to address gender, it does not identify specifics tactics for tackling the issue. Solomon notes that this problem can be attributed, in part, to a lack of diversity in tobacco control: Women are underrepresented in research, technology development, and public health leadership.

The consequences of this neglect are that there is little discourse in global health or women’s health about the fact that in many countries lung-cancer death rates exceed breast-cancer death rates among women.

Moving forward, women must help guide the development and adaptation of cessation and harm-reduction programs that have in the main been developed by using men as the “default option.” Finally, the starting point to gender analysis and policy is always to stratify and report smoking and outcome data by sex in all reports.

SS: You are the founder president of the Foundation for a Smoke-Free World. What is the one area of change you would like to see through the foundation’s intervention in the next five years globally?

DY: The most critical change – and it’s a sweeping one – would be a shift toward evidence-based decision making in the tobacco-control space. Too often, policy is driven by political or ideological factors, rather than science. As a result, global approaches to improving cessation effectiveness have stagnated and policymakers have banned tobacco harm-reduction products before seriously considering their benefits.

Indeed, a dearth of evidence-based guidance has yielded ad hoc policies that run counter to the goals of the FCTC. Consider, for example, the fact that some governments permit the sale of deadly combustible cigarettes, while banning safer e-cigarettes. My hope for the ensuing years is that the public health community adopts evidence-based policies, and that they help to broadcast research findings to clinicians, policymakers, and the public at large.

Sachi Satapathy is an international development practitioner who has worked on large-scale projects. His interests are in public policy, poverty alleviation and public-private partnerships for development in middle-income and developing countries.