Moving towards more equitable and integrated approaches for tobacco control and non-communicable diseases: invited commentary
- 1Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- 2Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
- Correspondence to Dr Asaf Bitton, Division of General Medicine, Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Rm 3-002P, Boston, MA 02120, USA;
Wipfli and Samet incisively describe the many challenges that the global non-communicable disease (NCD) movement faces, and the lessons tobacco control can offer it.1 Notably though, while global tobacco control offers one of the few proven strategies for NCD control, its successes have not been spread equally around the world. An inverse gradient of tobacco control success is emerging between wealth and tobacco burden (within and between countries). Stunning successes in reducing high tobacco use in the USA, Western Europe and Latin America stand in tandem with the large and often growing burdens of use and tobacco-induced disease in East Asia, parts of the former Soviet Union and Africa. The FCTC is a monumental transnational public health achievement, but has had uneven and delayed implementation in these high-burden poorer countries. Moreover, NCDs and tobacco share a tragic and often overlooked reality—both are growing disproportionately among the poor, the young and socially marginalised.2 3 This picture should spur action in both tobacco control and NCD civil society to promote a human rights-based approach that preferentially emphasises equity, access and implementation of both evidence-based treatments and policies.
A consensus is emerging in the NCD community that a broader ‘diagonal’ approach is necessary, emphasising both health systems strengthening and focused disease and risk factor targeting.4 But recent experience with broad health systems reform in poor countries showed limited success, and may have actually delayed adequate responses to emerging threats such as HIV. It was the belated realisation that effective HIV control required both prevention and treatment integrated within better functioning systems that finally spurred HIV burden reductions.5 Here tobacco control stands to learn well from these failures and promote a combined public health and treatment approach for NCDs. Tobacco control advocates should move beyond the stale debate around the cost-effectiveness of individual treatment versus population-based tobacco control measures. There is a clear ethical mandate to do both,6 and an evidence base that suggests that both are necessary to reduce population burden and immediately help those who cannot quit on their own today.7
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Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.