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© 2005 American Public Health Association
DOI: 10.2105/AJPH.2004.047167
GLOBAL TOBACCO CONTROL ISSUES |
Harry A. Lando is with the Division of Epidemiology and Community Health, University of Minnesota, Minneapolis. Belinda Borrelli is with the Center for Behavioral and Preventive Medicine, Brown University, Providence, RI. Laura C. Klein is with the Department of Biobehavioral Health, The Pennsylvania State University, University Park, Pa. Linda P. Waverley is with Research for International Tobacco Control, Ottawa, Ontario. Frances A. Stillman is with the Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md. Jon D. Kassel is with the Department of Psychology, University of Illinois at Chicago. Kenneth E. Warner is with the Department of Health Management and Policy, University of Michigan, Ann Arbor.
Correspondence: Requests for reprints should be sent to Harry A. Lando, Division of Epidemiology and Community Health, University of Minnesota, 1300 South Second St, Suite 300, Minneapolis, MN 55454–1015 (e-mail: lando{at}epi.umn.edu).
ABSTRACT
Smoking prevalence is shifting from more- to less-developed countries. In higher-income countries, smoking surveillance data, tailored treatments, public health campaigns, and research-based policy implementation have led to a decrease in tobacco use. In low- and middle-income countries, translating research into practice and policy is integral for tobacco control.
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We describe the landscape of existing resources, both financial and structural, to support global tobacco control research and strengthen research capacity in developing countries. We identify key organizations that support international efforts, provide examples of partnerships between developed and developing countries, and make recommendations for advancing global tobacco research.
There is a need for increased commitment from organizations to support global tobacco control research.
THE DECLINE IN SMOKING prevalence in high-income countries is attributable to a large extent to coordinated tobacco control efforts that are research-based, involving regional and population-specific epidemiological surveillance and intervention strategies that lead to implementation of tobacco control policies.1–4 An important first step to cultivating region-specific research is understanding the current landscape of resources available to support and strengthen research capacity as well as opportunities to foster collaboration among tobacco control researchers when appropriate. Researchers entering the tobacco control field often confront daunting challenges in identifying potential collaborators and gaining financial support for their projects. These challenges are multiplied when they undertake tobacco control efforts in developing countries in the face of cultural, political, and economic impediments.
ORGANIZATIONS SUPPORTING GLOBAL TOBACCO CONTROL RESEARCH
The first step in facilitating international collaboration and strengthening the capacity for research is to carefully assess the current landscape: to determine what resources are now available and what can be realistically accomplished with these resources. Toward this end, a list of organizations that currently support research in global tobacco control has been published in a report prepared by Research for International Tobacco Control (RITC), an international multidonor secretariat housed at the International Development Research Centre in Ottawa, Ontario.5 Table 1
provides a brief summary of the missions of selected agencies involved in supporting global tobacco control and tobacco control research as of 2002. The landscape in global tobacco control is ever shifting, and hence this listing is not entirely up to date. However, it does provide a starting point for tobacco control researchers and health care providers who are interested in accessing funding for international research on tobacco.
It is difficult, if not impossible, to determine the amount of money available for tobacco control research per se. Although the list in Table 1 is impressive, not all these organizations are granting agencies, and funds directly allocated to tobacco control research are limited. A review of Table 1 would suggest that this amount is surely less than $10 million for the entire globe, and perhaps closer to $5 million annually. Compare this expenditure with the $12.47 billion spent by the tobacco industry in 2002 on promotion and advertising in the United States alone.6 Researchers in basic tobacco science may have a particularly difficult time in securing funding given that the listed granting agencies generally emphasize applied and policy research.
Governmental and Institutional Support
The Fogarty International Center of the National Institutes of Health, with the support and collaboration of 5 institutes of the National Institutes of Health, the US Centers for Disease Control and Prevention, the Canadian Institutes of Health Research, and the World Health Organization’s Tobacco Free Initiative, established the International Tobacco Health Research and Capacity Building Program.7
This Fogarty International Center funding program is unique in supporting both trans-disciplinary research, including basic tobacco science and research involving partnerships between primarily US tobacco scientists and scientists in developing countries. Fourteen grants were awarded in response to an initial request for applications issued in 2001. The goals of the program are to reduce the burden of tobacco consumption in low- and middle-income nations by conducting observational, interventional, and policy research of local relevance and to build capacity in epidemiological and behavioral research, prevention, treatment, communications, health services, and policy research. A brief description of these 14 projects is included in Table 2
.
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Several institutes of the National Institutes of Health have also supported global tobacco research through other initiatives. The National Cancer Institute, for example, supports the Global Tobacco Research Network.8 The National Institute on Drug Abuse allows grantees to apply for administrative supplements to existing grants to add components focusing on international research. The institute also supports several types of programs for international scientists in collaboration with US grantees, including the possibility of bringing researchers from developing countries to the United States for pre- and postdoctoral training. The Environmental Protection Agency supported work in China to combat environmental tobacco smoke. Health Canada and the Canadian Institutes of Health Research support global tobacco research including the Canadian Tobacco Control Research Initiative.
RITC was established in 1995 and has had multiple funding partners, including the International Development Research Centre, Health Canada, the Swedish International Development Cooperation Agency, and the Canadian International Development Agency. RITC was invited to take the lead in developing tobacco control research strategies and global partnerships that would respond to tobacco as a major threat to equitable and sustainable development.
For the past 10 years, RITC has supported tobacco control research and has worked to strengthen research capacity in low- and middle-income countries. RITC accepts investigator-initiated research proposals that are based in developing country institutions. The RITC secretariat works closely with research proponents to refine research proposals and to provide technical support as needed. Priority is given to research that is policy relevant and multidisciplinary and includes a capacity-building component.
Private Foundations
Private foundations have provided support for tobacco control initiatives around the globe. The Trading Tobacco for Health initiative of the Rockefeller Foundation included developing a partnership between US researchers and the Thailand Health Promotion Foundation to support research capacity and skill development throughout Southeast Asia by providing seed funding to local investigators and by supporting workshops and training. The Open Society Institute focuses on central and eastern Europe, specifically former Soviet Union and satellite countries. The tobacco initiative is mandated to fund policy research in order to establish an evidence base for the development of advocacy strategies. Priorities include critical tobacco-related issues such as price policy, taxation, and smuggling.
International Organizations
The World Health Organization (WHO) and its regional offices have worked to support the Framework Convention on Tobacco Control, a momentous step for tobacco control in which nations have united around a treaty to protect public health by reducing the harmful impact of tobacco use. Countries that sign the treaty agree to design, implement, and periodically update their national tobacco control strategies and programs, including public education, product regulation, and taxation, in accordance with treaty requirements. WHO also implemented the Tobacco Free Initiative, which supports communication, media, and advocacy for policy change and works with countries to strengthen national capacity for the development of sustainable tobacco control activities. WHO regional offices have varied in their emphasis on tobacco control initiatives.
The World Bank has made critical contributions to global tobacco control research, especially through its emphasis on research on the economics of tobacco. The World Bank’s widely disseminated report Curbing the Epidemic: Governments and the Economics of Tobacco Control 9 has become a major resource for tobacco control advocates and researchers worldwide.
CAPACITY-BUILDING ORGANIZATIONS THAT DO NOT PROVIDE RESEARCH GRANTS
The International Tobacco Evidence Network emphasizes both interdisciplinary collaboration and communication between researchers in low- and middle-income countries and international experts in tobacco control. The network conducts country-specific research; has established regional centers in South Africa, Mexico, and Poland; provides peer reviews of manuscripts submitted by researchers from developing countries; and organizes regional workshops to promote research capacity building.
The International Tobacco Evidence Network emphasizes the economic research of tobacco control–related issues and provides technical support for such research. It seeks to encourage colleagues in low- and middle-income countries to undertake interdisciplinary analyses of tobacco consumption, providing them with both technical and strategic advice and helping them to identify research priorities. The network seeks to disseminate existing research-based knowledge and to monitor tobacco control research activities with an international aspect to identify research gaps.
The research capacity–building efforts by the network in Southeast Asia have demonstrated knowledge transfer by a series of successful grant applications from the region and by influence on formulating tobacco control policies in participating countries. One such success story is Vietnam, where analyses produced by a participant were presented at the ministerial level and were followed by the decision to increase taxes on tobacco products nationwide.
The Campaign for Tobacco-Free Kids primarily focuses on the United States and emphasizes policy and advocacy issues while providing technical assistance in these areas to both individuals and organizations. Moreover, the campaign synthesizes and disseminates the evidence-based literature to support important policy decisions. At this time, the campaign does not have a specific mandate to support international tobacco control research, but it was involved in assisting researchers from low- and middle-income countries to locate US partners to apply for funding from the Fogarty International Center. The campaign played a key role in drafting and gathering support for a concept statement identifying tobacco control research as a priority area for the Gates Foundation’s "grand challenges" in global medical research. The campaign was also a major supporter of the Framework Convention on Tobacco Control treaty described previously, through its work with the Framework Convention Alliance, an international network of tobacco control nongovernmental organizations.
The Society for Research on Nicotine and Tobacco, more than any other single organization, has emphasized nicotine and tobacco research. One of its key missions is to stimulate the generation of new knowledge concerning nicotine in all areas, from molecular to societal. However, SRNT’s membership and focus have been primarily on a relatively few high-income regions, namely, North America, Europe, and Australia, with only 15% of its membership from outside North America. More recently, SRNT has sought to expand its work and membership into other regions. The 2003 annual meeting included a preconference meeting led by H. A. L. that included scientists from North America and abroad reporting on progress made in international collaborative efforts in terms of country-specific research and on strengthening research capacity in developing countries.
The 2005 SRNT scientific meeting will be held in Prague; this is the first time the annual meeting will take place outside North America. SRNT is continuing to promote membership of international researchers, especially from developing countries, by waiving conference registration fees, sponsoring travel to conferences, offering a limited number of free memberships, and sponsoring receptions and scientific sessions at international conferences.
The Institute for Global Tobacco Control at the Johns Hopkins Bloomberg School of Public Health is another important resource that is helping to broaden and expand global tobacco control research. The institute has been a major source of training and technical assistance and has conducted survey research and convened a number of conferences and workshops focused on global tobacco control work. The institute, through funding from the Rockefeller Foundation, has been able to support a number of small seed projects, primarily in Southeast Asian countries, and is conducting research and infrastructure development in Mexico, Brazil, and China as part of its Fogarty Initiative.
The Global Tobacco Research Network, which is supported by funding from the National Cancer Institute, is now housed under the umbrella of the Institute for Global Tobacco Control. Stillman and colleagues describe the network in greater detail in this issue.8
GLOBALink is another critical resource that has unique potential for linking researchers and advocates internationally and for disseminating information on tobacco control. Since 1993, GLOBALink has been bringing together tobacco control professionals around the world with a view to providing them with the opportunity to network, exchange ideas, and share information. With a membership of more than 4000 tobacco control advocates, GLOBALink is a recognized catalyst for dialogue and collective action.
EXAMPLES OF SUCCESSFUL RESEARCH CAPACITY BUILDING
A few thousand dollars in developing countries can support substantial research projects that may include collection of extensive survey data, moderate-sized randomized clinical trials, and stipends for investigators. H. A. L., for example, has worked with a student to conduct a comparative assessment of Chinese and US college student attitudes and behaviors relevant to tobacco and alcohol. This work was funded by a $2500 graduate research award.10 RITC has supported similar efforts with relatively modest funding. For example, RITC supported the fieldwork of master’s and doctoral degree students from low-income countries such as Nepal and Turkey for less than Can $5000 each. RITC has funded small grant competitions in the southern Africa region and the Middle East for as little as Can $20 000. Researchers in South Africa contributed to the evidence base that spawned that country’s tobacco control legislation. The resulting tobacco tax increases led to a decrease in smoking prevalence in South Africa. Most recently, RITC partnered with the Canadian Tobacco Control Research Initiative and the American Cancer Society on a research competition for small grants to support ratification, implementation, or enforcement of the Framework Convention on Tobacco Control.
RITC also promotes dissemination of research results, particularly to policymakers. A recent publication with the World Bank, Tobacco Control Policy: Strategies, Successes and Setbacks,11 tells the stories of tobacco control policy-making in 6 diverse countries and demonstrates the varied and important roles played by activists, health practitioners, policymakers, researchers, nongovernmental organizations, politicians, and the press.
Training international tobacco researchers is a critical step to ensure international collaboration and solid science. Kassel and Ross consider training issues in an accompanying commentary in this issue.12
DISCUSSION: RECOMMENDATIONS FOR GAINING A FOOTHOLD
The global tobacco epidemic continues to grow and spread to less developed countries that do not have the resources or infrastructure for tobacco control. Partnerships between the research community and those who apply research findings (practitioners, advocates, and representatives of both nongovernmental organizations and governmental organizations) are essential for success. These partnerships can mobilize financial resources and can facilitate knowledge transfer both to policymakers who need an evidence base on which to build policy recommendations and to the general public to increase awareness of the consequences of tobacco use.
Financial Resources
Tobacco control researchers and advocates should encourage the organizations listed in Table 1 to increase their financial commitments to tobacco control, as well as target other organizations to add tobacco control to their portfolio.
The United Nations Children’s Fund (UNICEF) has focused primarily on children’s health globally and is thus well positioned to support global tobacco prevention efforts. Although UNICEF has indicated interest in tobacco control issues, it has not yet made a major financial commitment to tobacco control efforts directed at children. Development agencies, most notably the US Agency for International Development, could also increase attention to economic threats posed to poorer countries by tobacco production and consumption and could provide dramatically greater financial support for initiatives to reduce tobacco’s adverse impact on health and society. Perhaps in the future, the Gates Foundation can be persuaded to recognize tobacco control research as a grand challenge in global health, especially given its partnership with the National Institutes of Health. In the Ottawa Declaration on Tobacco and Sustainable Development13 resulting from the November 2002 RITC-hosted meeting, Bridging the Research Gaps in Global Tobacco Control,5 participants called on the development community to recognize the enormous threat to human life and health and, more broadly, to sustainable development and poverty reduction posed by tobacco use.
A key question is whether a sufficiently compelling case can be made to governments to devote tobacco tax monies to tobacco control efforts, including research. Thailand, for example, increased taxes on tobacco products, and the resulting revenues have been used to fund a comprehensive tobacco control program.11 The message should be clearly communicated that research can help to inform and drive policy and that locally relevant research can be especially important in this regard (see Warner14 in this issue). In Taiwan, for example, researchers estimate that tobacco-related disease is costing the government $571 million per year, with 20% of illnesses and deaths directly related to tobacco smoking. Nearly 48% of Taiwanese men smoke, compared with 5.1% of women, although the percentage of adolescent girls who smoke is on the rise.15 Fortunately, Taiwanese officials have taken notice of these alarming data and, as a result, have passed various tobacco acts and Department of Health initiatives to promote tobacco control.16
International Linkages
Home to active and aggressive multinational tobacco industries, wealthier countries would appear to have an obligation to poorer regions of the world increasingly being targeted for tobacco sales. These developed countries also should be encouraged to build linkages with governing health organizations of less developed countries, working with them on ways to provide funding and resources to local tobacco control researchers and advocates. The May 2003 approval of the Framework Convention on Tobacco Control is an important first step in this direction.17
We hope that tobacco research will be viewed in developing countries as a worthwhile endeavor and that those individuals who engage in such research will have opportunities for appropriate academic and research appointments and professional advancement. Organizations such as SRNT can play a critical role in bringing together diverse constituencies of researchers, practitioners, and advocates to identify common interests. Currently there may be little contact among professionals concerned with tobacco control even when they are operating in close physical proximity. Establishing closer linkages is especially important in developing countries where the tobacco control infrastructure may be extremely limited.
CONCLUSION
In less developed countries, even relatively modest financial resources can be parlayed into large tobacco control initiatives that have the potential to save millions of lives around the globe. It is our hope that the landscape for global tobacco control will improve dramatically in the future and that far more coordinated efforts, additional resources, enhanced infrastructure, and a substantially increased cadre of researchers across disciplines will focus on confronting the rising tobacco epidemic. The Framework Convention on Tobacco Control treaty is a momentous step that, among other things, legitimizes tobacco control efforts, enabling tobacco researchers to use the treaty as leverage for motivating their own countries to shift priorities and support tobacco control research and policy. The potential for success is great; the consequences of failure to act are literally millions of preventable deaths around the world, primarily in developing countries.
Acknowledgments
We acknowledge the contributions of Mary Leitschuh.
Footnotes
Contributors
All the authors were involved in the writing and conceptualization of this article. All authors reviewed and commented on successive drafts. H. Lando took the lead in preparing the drafts. L. P. Waverley contributed substantially to Table 1.
Accepted for publication October 20, 2004.
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13. International Development Research Center. Ottawa Declaration on Tobacco and Sustainable Development. November 6, 2002. Ottawa, Canada. Available at: http://www.idrc.ca/tobacco/Ottawa_Statement_E.htm. Accessed November 14, 2003.
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K. E. Warner The Role of Research in International Tobacco Control Am J Public Health, June 1, 2005; 95(6): 976 - 984. [Abstract] [Full Text] [PDF]
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F. A. Stillman, H. L. Wipfli, H. A. Lando, S. Leischow, and J. M. Samet Building Capacity for International Tobacco Control Research: The Global Tobacco Research Network Am J Public Health, June 1, 2005; 95(6): 965 - 968. [Abstract] [Full Text] [PDF]
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