This is one of our charity profiles, where we present our shallow, preliminary research on a potential, promising charity idea. We believe that this idea could be a potential contender for a GiveWell top charity, if further research confirmed the idea and if someone started the charity, executed it well, and resolved some of our outstanding questions and reservations.
Lobby low and middle-income countries (LMIC) to increase tobacco taxes.
Cost-effectiveness: High -- Studies claim this to be one of the most cost-effective interventions, with $/DALY figures more cost-effective than estimates for most other interventions. (However, these cost-effective estimates shouldn’t be taken literally and expect the true cost-effectiveness to potentially be much lower.)
Strength of Evidence: Medium -- The case for tobacco taxation is covered by several studies, including some systematic reviews. However, we are concerned there is a lack of research on key lobbying related factors, such as counterfactuals, average campaign time, and the base rate of successful campaigning.
Counterfactual Scalability: High -- If this was successful in one country, it seems like we could easily adapt the infrastructure to other countries. Moreover, there is only a few large organizations and two large funders working in the area, suggesting large room to grow.
Ease of Testing: Low -- Performing an impact evaluation on a lobbying campaign is exceedingly difficult due to high interference from other campaigns, the all-or-nothing nature of lobbying, and an inability to effectively randomize.
Flexibility: Medium -- While it appears we could move lobbying efforts to other areas as we gain more generalized skills and contacts, we would likely not build much infrastructure that is useful for areas outside lobbying.
Logistical Possibility: Medium -- Lobbying poses significant logistical challenges and draws on skills we do not yet possess.
Why We Think This Could be an Effective Opportunity
There’s strong evidence that increasing tobacco taxation reduces tobacco consumption and that reduced tobacco consumption results in improved health outcomes (International Agency for Research on Cancer, 2011; Jha, et. al., 2013). Without cessation increases, tobacco use may account for some 10 million deaths per year by 2030, with most deaths occurring in LMIC (Ibid.). For example, in India, smoking accounts for nearly 40 percent of tuberculosis deaths among middle-aged males, or about 120,000 deaths annually. (Jha 2012).
WHO (2011) estimates a 10% price increase in tobacco causes a 4% reduction in tobacco consumption. Jha, et. al. (2013b) estimates that increasing taxes to the World Health Organization (WHO) recommended level of 70% of total sale price in all LMIC would result in an 11-27% decrease in smoking mortality and therefore save tens of millions of lives.
There are also numerous pieces of evidence suggesting that government implementation of tobacco taxation is highly cost-effective. Savedoff and Alwang, (2015), writing for the Center for Global Development, price tobacco taxation as $3 - $70 per DALY averted. Jha, et. al., (2013), writing for the Copenhagen Consensus, estimates a 4000% return, with a $500M/yr tobacco control program averting more than one million deaths annually. Jha, et. al., (2013) also states that tobacco taxation is the most important and most cost-effective portion of the tobacco control campaign. A systematic review of 84 studies also found that taxation was among one of the more effective tobacco control initiatives (Thomas, et. al., 2008). Experts we spoke to at tobacco lobbying campaigns and evaluative organizations (e.g., the DCP3) also broadly agreed that this was a strong area.
A Possible Implementation Plan
The most plausible route we identified was hiring local lobbyists and tobacco control experts to implement tobacco taxation legislation at the national level. Our starting point would be consulting the Framework Convention on Tobacco Control, which provides tax policy specifics, refutations of tobacco industry talking points, and guides for lobbying policy makers. The WHO Framework for Tobacco Control also contains additional information.
We think it is best to focus tobacco taxation campaigns on lobbying LMIC because the costs of lobbying are significantly lower than the developed world and there is less existing lobbying efforts in place.
There are many LMIC that fall beneath the WHO policy prescriptions for tobacco control which recommend taxation make up 70% of cigarette costs. Campaign for Tobacco-Free Kids (CTFK), a large non-profit working in the area, has prioritized their campaigns in most LMIC with a high burden of disease from tobacco that are also not facing violent internal conflict. If we were to work in one of those countries it would make sense to partner with them.
We might be interested in working where CTFK isn’t, so that we can test our counterfactual impact free from the involvement of other campaigns. We very weakly think that Ethiopia may be a promising place to start, based on some preliminary research. CTFK has not prioritized Ethiopia, perhaps because of their low overall smoking rates. However, Ethiopia has a large population and they recently banned smoking in public places, which suggests political will may exist for further tobacco control.
Who is Already Working in this Area?
Our research suggests that Bloomberg Philanthropies and the Bill and Melinda Gates Foundation are currently the dominant funders in this area.
Callard (2010) estimated no more than $240M is spent annually on tobacco control, worldwide, but this could be out of date due to more recent grants and GiveWell has argued that this study makes fairly aggressive assumptions (GiveWell report on tobacco control). Between 2007 and 2015, Bloomberg Philanthropies reportedly committed $600 million to combat tobacco use worldwide (Bloomberg press release, 2015), which amounts to $75M/yr. In 2008, the Bill and Melinda Gates Foundation pledged $125M over five years ($25M/yr) to tobacco control, including a $24M grant to Bloomberg (BMGF press release, 2008).
CTFK has several tobacco control initiatives, including a focus on taxation.
PSI in India ran Quitline from 2011 to 2013, which was a telephone help line primarily offering counselling to help people quit tobacco addiction. They encouraged the Indian government to continue the campaign, which, according to PSI, the government is planning to do but has not (Ibid.). In 2015, PSI in India also started a campaign to reduce exposure to second-hand smoke and tobacco use among minors (Ibid.).
WHO offers technical assistance for governments trying to implement tobacco control.
Resource Centre for Tobacco Free India is an advocacy and research group that has implemented various tobacco control initiatives, including taxation.
The Economics of Tobacco Control Project, based in South Africa, creates new research and train NGOs about tobacco control initiatives, including taxation.
The evidence for lobbying succeeding in LMIC is far weaker than the evidence for the impact of successfully implemented tobacco taxation. It’s often difficult to credit responsibility for legislative change to particular players in advocacy campaigns because multiple campaigns operate simultaneously and it’s unclear whether the government would have changed anyway, absent lobbying efforts. While there is considerable evidence the government implementation of tobacco taxation is highly cost-effective, there is a dearth of analysis on the return of investment of actual lobbying campaigns.
We find the difficulty of testing this project to be a barrier to attempting an implementation, given our desire for rigorous impact evaluation and prioritizing against other charity ideas, as well as this making it difficult to receive feedback to refine our tobacco taxation approach. However, depending on local tax policy, this specific charity idea may be able to be completed at the state level before attempting it on the national scale.
We’re also not enthusiastic about would could be the zero-sum and all-or-nothing nature of lobbying. We may not only have to be effective enough to lobby the government and beat the status quo but we may have to be more effective than the pro-tobacco interests lobbying the government. It seems quite possible that we could spend a significant amount of resources lobbying and not accomplish any actual legislative outcomes. According to some experts we spoke to, legal attacks on lobbying efforts from tobacco companies are also somewhat common.
It would very likely be necessary to hire local lobbyists to reach the needed policy makers, which could be expensive. This also creates flexibility concerns, as the contacts we build would likely not be useful for a charity other than lobbying. Moreover, if lobbying requires a high degree of specialization, it may not even be possible to move easily between different lobbying campaigns.
Funding could be a concern, especially if we were seeking a diversity of sources. While this intervention has large support from the global health community, there aren’t many large funders in this specific area. This could, however, suggest that the area is neglected.