[PPT] - Do Does Globalization Weaken Nat National Polic licy Autonomy an PowerPoint Presentation

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Do Does Globalization Weaken Nat National Polic licy Autonomy an and Ha Harm Public Hea Health? Eviden ence fr from Tobacco

ASHLEY M. FOX, PHD, MA ASHWIN RAMASWAMY, MD ACADEMYHEALTH, GLOBAL HEALTH SESSION 28 JUNE 2016, BOSTON, MA

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Background Whereas smoking prevalence has been decreasing in industrialized countries, it is on the rise in many low and middle income countries.

MEN WO- MEN

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Background

Public health advocates link rising smoking rates in developing countries to

international trade agreements that preempt national implementation of policies designed to curb smoking.

International trade agreements, such as the Trans-Pacific Partnership, contain

provisions that enable tobacco companies to challenge domestic public health policies that are viewed as barriers to trade.

These include:
the banning of flavored cigarettes,
advertising restrictions,
graphic warning labels and
tobacco taxation.

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Examples of How Trade Agreements infringe on National Policy Autonomy

Challenges to Banning Flavored Cigarettes in US US, 2009, Family Smoking Prevention and Tobacco Control Act was signed into law

Banned the sale of flavored cigarettes in the US,

including candy, fruit, and spice flavors to reduce teen smoking

In 2010, Indonesia—the world’s largest producer of

clove cigarettes—alleged that the law was inconsistent with US trade obligations under various World Trade Organization’s (WTO) agreements.

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Examples of How Trade Agreements infringe

n National Policy Autonomy, cont.

Challenges against Australia’s Plain Packaging Law In 2011 Australia passed legislation to create uniform cigarette packaging with brand names would be listed in small font and large pictorial warnings/a quit-line phone number comprising the remainder. Philip Morris Asia sued Australia, arguing that the bill violates conditions of a 1993 investment agreement between Hong Kong and Australia. The case is being heard by a tribunal at the UN. Separately, several tobacco-producing nations (Honduras, Ukraine, Cuba, and the Dominican Republic) claim that Australia’s policy is overly restrictive and contradicts trademark protections afforded by various WTO agreements.

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Examples of How Trade Agreements infringe

n National Policy Autonomy, cont.

Disputes against Uruguay’s Warning Labels In 2006, the Uruguayan government passed regulations to tough its warning labels. In 2010, the Swiss operational hub of Phillip Morris filed suit at the World Bank, claiming that government’s regulations violate a 1991 bilateral investment treaty between Uruguay and Switzerland.

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Examples of How Trade Agreements infringe

n National Policy Autonomy, cont.

In US Trade Agreements with the following countries, cigarette imports are required to be tariff free:

Chile (2004),
Singapore (2004),
Peru (2009),
South Korea (2011),
Colombia (2011), and
Panama (2011)

This means that these countries cannot tax the importation of a product into their country that is known to be harmful to the health of their public.

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Research Question

Little empirical evidence exists regarding the effects of trade

penness on domestic tobacco policies and smoking prevalence.
Country smoking rates may be more a function of economic development

(modernization theory)

Rise of unhealthy lifestyles as citizens have more disposable income
Cultural globalization may give rise to increased smoking rates to appear

“modern” or “western” (diffusion theory)

Countries may ignore trade rules or find ways around them

Do countries that are more economically or culturally globalized smoke more and have weaker anti-smoking laws?

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Methods

1. We assess predictors of smoking prevalence across countries over

time (1989-2012).

2. We examine characteristics of countries with stronger anti-

smoking policies to assess whether globalization reduces national policy autonomy (2008, 2010, 2012).

Main IV: Globalization indices
Controls: GDP per capita, cigarette imports/exports, age structure of

country, democracy, region.

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Methods: Data and Sources

DVs= Smoking Prevalence (150 countries, 1989+).

Prevalence of daily smoking for all types of tobacco. Source: The IHME houses the data published in the

study, Ng M, Freeman MK, Fleming TD, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA. doi:10.1001/jama.2013.284692.

Anti-Smoking Policies. (128 countries, 2008, 2010, 2012). Source: WHO Data Repository

IV= Globalization. Source: Konjunkturforschungsstelle (KOF) index of globalization, Swiss Economic Institute.

Economic globalization: Trade flows-FDI, stocks, portfolio investment, income payments to foreign

nationals; Trade restrictions- hidden Import barriers, mean tariff rate, taxes on international trade.

Social globalization: Information flows- number of internet users per 1000 people, televisions per 1000

people, and trade in newspapers as a percent of GDP; Personal contacts-international telephone and mail traffic per capita, transfers (% GDP), international tourism, % population that is foreign.

Cultural globalization: Number of McDonald's restaurants per capita; number of Ikea per capita and

trade in books.

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Methods: Data and Sources

Controls GDP per capita. Source: World Development Indicators

Democracy. Polity IV measure-ranges from full autocracy (0) to full democracy (100)

Domestic Cigarette Imports and Exports. Source: FAO stats Region: North America; Latin America and the Caribbean; Eastern Europe and Central Asia; Western and Northern Europe; East Asia and the Pacific; sub-Saharan Africa; Middle East and North Africa. Population over age 65. Source: World Development Indicators

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Hypotheses

Countries with rising degrees of economic globalization should have increasing rates of smoking and fewer anti-smoking laws over time. On the other hand, it is possible that entering trade regimes and engagement in global economic activity has no direct effect on national policy autonomy or the degree to which people smoke. Rather, smoking rates may be increasing in countries due to processes of economic development and Westernization.

In this instance, we would expect to see that as country GDP increases, smoking rates increase.
Likewise, countries with rising degrees of cultural globalization should see higher increases in smoking

rates.

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Analysis

Smoking Prevalence Models

GEE models (xtgee command in Stata 13), which takes into account the over-time correlations
f the data for the period 1989-2012.
All countries, LMICs only

Anti-Smoking Policy Models

Ordered logistic random effects models (xtologit command in STATA 13)

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All countries LMICs (1) (4) (1) (4) VARIABLES prevalence prevalence prevalence prevalence Overall Globalization 0.06*** 0.02** (0.040 - 0.077) (0.000 - 0.042) Econ Globalization 0.04*** 0.02*** (0.022 - 0.048) (0.006 - 0.035) Social Globalization 0.01

0.01

(-0.015 - 0.042) (-0.043 - 0.020) Cultural Globalization

0.00

0.01 (-0.013 - 0.011) (-0.009 - 0.019) GDP per capita

0.00***
0.00***

0.00*** 0.00*** (-0.000 - -0.000) (-0.000 - -0.000) (0.000 - 0.000) (0.000 - 0.000) Over 65 pop

0.18***
0.12**
0.30***
0.25***

(-0.268 - -0.084) (-0.212 - -0.019) (-0.444 - -0.149) (-0.412 - -0.090) Cigarette Exports

0.00*
0.00*
0.00***
0.00***

(-0.000 - 0.000) (-0.000 - 0.000) (-0.000 - -0.000) (-0.000 - -0.000) Cigarette Imports

0.00
0.00**

0.00 0.00 (-0.000 - 0.000) (-0.000 - -0.000) (-0.000 - 0.000) (-0.000 - 0.000) Polity IV 0.05*** 0.04*** 0.04*** 0.03** (0.019 - 0.072) (0.013 - 0.069) (0.014 - 0.064) (0.004 - 0.056) North America (ref) ref ref Europe and Central Asia 6.08 5.66 ref ref (-1.623 - 13.779) (-2.064 - 13.377) Latin America and the Carribean

7.56*
8.05**
14.22***
14.73***

(-15.453 - 0.339) (-15.983 - -0.112) (-18.003 - -10.435) (-18.625 - -10.827) Middle East and North Africa

4.75
4.75
8.37***
7.80***

(-12.716 - 3.222) (-12.826 - 3.335) (-12.543 - -4.205) (-12.355 - -3.255) East Asia and the Pacific 2.04 1.71

1.30
1.48

(-5.935 - 10.018) (-6.298 - 9.714) (-5.492 - 2.884) (-5.712 - 2.758) South Asia

2.32
2.19
5.64**
5.54**

(-11.260 - 6.613) (-11.167 - 6.783) (-11.157 - -0.131) (-11.066 - -0.021) Sub-Saharan Africa

12.00***
12.72***
16.42***
16.93***

(-19.786 - -4.206) (-20.560 - -4.875) (-19.712 - -13.132) (-20.342 - -13.520) Constant 23.51*** 24.03*** 28.87*** 28.99*** (15.835 - 31.186) (16.304 - 31.754) (25.867 - 31.869) (25.854 - 32.135) Observations 3,032 3032 1,997 1997 Number of groups 150 150 102 102 ci in parentheses, *** p<0.01, ** p<0.05, * p<0.1

Results: Smoking Prevalence Models

*Year included but not shown

Globalization

positively predicts smoking prevalence, and this is mostly driven by economic globalization.

Higher GDP also

predicts smoking prevalence among LMICs.

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1 1 VARIABLES Tobacco Policy Index Tobacco Policy Index Overall Globalization 0.01 (-0.047 - 0.066) Economic Globalizaation

0.02

(-0.074 - 0.034) Social Globalization 0.02 (-0.076 - 0.107) Cultural Globalization

0.02

(-0.067 - 0.029) GDP per capita (-0.000 - 0.000) (-0.000 - 0.000) Population over 65 0.1 0.14 (-0.111 - 0.314) (-0.084 - 0.364) Smoking prevalence

0.05
0.06

(-0.165 - 0.059) (-0.172 - 0.053) Cigarette Import Value

0.00*

(-0.000 - 0.000) (-0.000 - 0.000) Tobacco Import Value (-0.000 - 0.000) (-0.000 - 0.000) Cigarette Export Value (-0.000 - 0.000) (-0.000 - 0.000) Tobacco Export Value (-0.000 - 0.000) (-0.000 - 0.000) Democracy (Polity IV) 0.07 0.09 (-0.046 - 0.179) (-0.034 - 0.204) 2008 (ref) 2010 1.50*** 1.54*** (0.851 - 2.157) (0.876 - 2.202) 2012 2.77*** 2.81*** (1.994 - 3.544) (2.017 - 3.598) Observations 356 343 Number of ncode 128 123

*Region included but not shown

Results: Anti-Smoking Policy Index

No relationship

btw globalization and anti-smoking policies.

Anti-smoking

policies have gotten stricter

ver time.

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Conclusions

Economic globalization does predict higher smoking rates, but it does not predict weaker anti- smoking policies. Higher GDP also predicts higher smoking rates, but not weaker anti-smoking policies. In fact, none of the variables expected to predict weaker anti-smoking policies did including the amount of cigarette and tobacco imports. Anti-smoking policies have been getting stronger over time in spite of challenges from global trade regimes.

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Relationship btw economic globalization and smoking prevalence seems to be getting stronger with time

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11 Countries with most aggressive anti- smoking policies in 2012

Country Tobacco Policy Index 2008 Tobacco Policy Index 2010 Tobacco Policy Index 2012 Brazil 17 17 27 Panama 8 27 27 Iran 24 26 26 Turkey 6 20 25 Mauritius 10 24 25 Albania 19 23 24 Colombia 2 21 23 Spain 16 22 22 Uruguay 13 22 22 Djibouti 21 22 22 Australia 20 20 21

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Appendix: Measuring Anti-Smoking Policies

Anti-Smoking Policy Index consists of:

Whether government objectives on tobacco control exist;
Whether a national agency for tobacco control exists;
Existence of smoke–free air laws in public places;
Availability of smoking cessation technologies and whether the cost is covered by the government;
Presence of warning labels on cigarettes;
Enforced bans on tobacco advertising;
Excise taxes on tobacco;
National television, radio, news, magazine, billboards bans on cigarette advertising;
Fines for violations of direct advertising bans.

We summed the measures to create a composite index of anti-smoking policy aggressiveness, which ranged from 0-27 (with 0 representing a country with no restrictions on smoking and 27 being the country with the most cumulative restrictions).