Big Tobacco^source spent the second half of the 20th century exploiting trade rules and advertising to increase its reach and snare new customers.^source Many low- and middle-income countries had domestic tobacco industries, but their governments were unprepared to counter the onslaught of multinational companies. Bolstered by a growing body of scientific evidence, backlash eventually galvanized global action. In particular, the 2003 WHO Framework Convention on Tobacco Control (FCTC) provided a strong foundation for international tobacco control.^source

Still the global burden of tobacco-related disease is staggering: 6.3 million deaths and 156 DALYs were attributed to tobacco use in 2010.^source The burden is concentrated in low- and middle-income countries, home to 80 percent of all smokers, and disproportionately borne by society's poorest strata.^source People pay a high cost for their addiction; smokers living in poverty use scarce resources that could otherwise pay for food, health care, or education. The poor also suffer disproportionately from tobacco-related illnesses and subsequently high medical costs.^source

In Thailand as elsewhere in Southeast Asia, smoking grew in popularity during the 20th century. By 1991, nearly 60 percent of adult men and 5 percent of adult women were regularly lighting up cigarettes.^source Smoking was far more common among the poorest quintile of Thai households, where men were almost twice as likely to smoke as their counterparts in the richest fifth of Thais.^source Ubiquitous tobacco use took a serious health toll in Thailand. By 1990, lung cancer was the second most common cancer among men.^source  Chronic and respiratory diseases were also on the rise, leading experts to predict that two million Thai children would eventually die from smoking.^source

Beginning in the 1940s, Thailand’s government had kept the tobacco industry under tight control, outlawing foreign products and protecting the government-owned Thai Tobacco Monopoly (TTM). The Thai Medical Association had secured health warnings and smoking bans.^source However, in the 1980s, early tobacco control gains encountered a dangerous adversary: multinational tobacco companies. Thailand and its fellow “Asian tigers," with large populations and booming economies, were attractive targets for Big Tobacco.^source Although the Thai government prohibited foreign tobacco products, international brands were still able to flood Thai media with advertisements. Frightened by the specter of competition, the TTM itself began advertising.^source

TASCP’s approach quickly paid off. In 1988, TASCP pressure led the government to revoke its approval for the TTM to build a new factory, and its lobbying helped secure a ban on cigarette advertising the following year. But poor enforcement of the advertising ban meant international tobacco companies continued to flout the regulation. And in 1989, Big Tobacco successfully petitioned the General Agreement on Trade and Tariffs to strike down Thailand’s import ban; Thailand allowed the first sales of foreign tobacco products in 1991. However, the forceful trade dispute had mobilized public opinion against tobacco companies. Over the following two decades, the coalition of advocates led by TASCP seized the public momentum and pushed for tough new laws to curb tobacco use and distribution.^source

Thailand's approach to tobacco control was multifaceted and comprehensive, targeting both supply and demand while also tackling secondhand smoke exposure.

The extensive set of control measures included seven approaches:

Between 1991 and 2009, Thailand progressively upped excise taxes on cigarettes from 55 percent to 85 percent of the factory price. Tobacco products were also subject to normal value added tax (VAT), a special “health tax” of 2 percent to fund anti-tobacco health promotion (as of 2001), and later an additional surcharge to fund the Thai Public Broadcasting Service.^source

The 1992 Tobacco Products Control Act prohibited sale of cigarettes to children under 18, banned distribution of free samples of tobacco products, and forbade the sale of tobacco products in vending machines.^source

The Tobacco Products Control Act outlawed ads for nontobacco products using tobacco brand names and the use of contests and promotions that could incentivize tobacco purchases.^source In 2005, Thailand strengthened the ban by prohibiting tobacco ads at the point of sale.^source

Starting in 1993, Thailand’s modest carton warnings became larger and more gruesome. New regulations required that graphic rotating health warnings cover at least a quarter of the total package surface, a portion that increased to over half by 2009.^source

In 2001, the Thai government established the Thai Health Promotion Foundation (ThaiHealth) as an autonomous state agency. ThaiHealth receives about US$120 million per year from a specially earmarked 2 percent tax on all tobacco and alcohol sales.^source The organization works with nongovernmental organizations and the public to support to support anti-tobacco campaigns and tobacco surveillance.

In 1992, the Thai government passed the Non-Smokers’ Health Protection Act, which gives the Ministry of Public Health authority to limit smoking in public places.^source The first set of smoke-free locations included public transport and cinemas, and limited smokers to designated areas in places like schools, hospitals, and museums.^sourceThe Ministry of Health has expanded the list of "smoke-free" zones repeatedly over time.

Since 1976, regular household surveys have assessed smoking prevalence and tracked trends.^source As a signatory to the FCTC, Thailand submits regular reports on progress to the WHO.^source From 2009, Thailand also became one of 16 low- and middle-income countries to participate in the WHO’s Global Adult Tobacco Survey (GATS), helping to monitor tobacco use, secondhand smoke, attitudes, enforcement of banned areas, and illicit advertising.^source

Decades after Thailand’s tobacco control efforts began, the long-term trends are clear: following Thailand’s crackdown on Big Tobacco, smoking rates declined significantly, and health gains are starting to emerge. Between 1991 and 2007, smoking prevalence among Thai adults declined from 59 percent to 42 percent among men, and from 5 percent to 2 percent among women.^source

Using the widely validated SimSmoke model, researchers estimated that Thailand’s smoking rates in 2006 were 25 percent lower among men and 24 percent lower among women than they would have been if not for the new laws and regulations. They also estimated that the policies saved roughly 32,000 lives between 1991 and 2006—and if current trends continue, a total of nearly 320,000 lives will be saved by 2026.^source

Thailand’s reduction in smoking prevalence has started to improve health. Between 1987 and 1997, the adult male mortality rate had gradually increased from 21 percent to 27 percent and the adult female mortality rate had remained near constant between 13 percent and 14 percent. Over the next decade and a half, however, those trends reversed: by 2012, the adult mortality rate had fallen to 21 percent among men and 11 percent among women.^source

Many factors underlie Thais’ lengthening life span, and reductions in smoking undoubtedly played a key role.

The health payoff also shows in incidence trends for many diseases attributable to smoking. For example, lung cancer incidence in men skyrocketed from 4 cases per 100,000 people in 1985 to 27 cases per 100,000 people in 1997. But incidence plateaued over the next decade and was under 25 cases per 100,000 people from 2001 to 2003.^source

Many tobacco control measures are actually cost saving due to the revenue generated from increased taxes, the low cost of legislative interventions, and the reduced burden on the health system. Other effective measures, such as mass media campaigns and the creation of government agencies to enforce tobacco laws, require a substantial upfront investment.^source Nonetheless, they are highly cost-effective: the WHO has estimated that a comprehensive tobacco control package costs just US$0.11 per person per year.

In Thailand, the only major expense came via the ThaiHealth health promotion fund, which was financed through surcharges on alcohol and tobacco. Even better, tobacco taxes provided a major source of revenue for the government—nearly US$2 billion in 2011—that could be reinvested in improving population health.

Thailand’s approach was also highly cost-effective at just US$74.40 per DALY averted. This estimate was based on the death and disability from three major tobacco-related health outcomes (lung cancer, COPD, and cardiovascular disease), which amounted to a combined of 541,695 DALYs averted, and the estimated cost of Thailand’s program from 1991 to 2006, which was US$25 million.^source

Many tobacco control measures are actually cost saving due to the revenue generated from increased taxes, the low cost of legislative interventions, and the reduced burden on the health system. Other effective measures, such as mass media campaigns and the creation of government agencies to enforce tobacco laws, require a substantial upfront investment.^source Nonetheless, they are highly cost-effective: the WHO has estimated that a comprehensive tobacco control package costs just US$0.11 per person per year.

In Thailand, the only major expense came via the ThaiHealth health promotion fund, which was financed through surcharges on alcohol and tobacco. Even better, tobacco taxes provided a major source of revenue for the government—nearly US$2 billion in 2011—that could be reinvested in improving population health.

The win-win economics of tobacco control also helped maintain political commitment. Antismoking activists proposed a new source of government revenue, which helped gain support from the minister of finance.^source With proceeds from the tobacco tax forming an increasing share of government revenue, opposition within the government receded. Likewise, advocates were able to secure funding for ThaiHealth by proposing an earmarked surcharge on top of the existing excise tax, rather than appealing for a share of existing funds.^source

One point of concern is an uptick in smoking prevalence among young people ages 15 to 24, from 20 percent in 2009 to 22 percent in 2011. Younger smokers are far more likely than their elders to purchase individual cigarettes instead of full packs and prefer manufactured cigarettes to roll your own.^source This suggests a trend towards embracing international consumerism.

But the fight isn’t over. Big Tobacco continues to buy political influence and identify loopholes to gain market share. For instance, the much-preferred roll-your-own cigarettes remain largely outside the scope of legislation and cigarette smugglers often evade taxes as well as prosecution.^source Plus, enforcement of laws is often uneven, particularly outside Bangkok.^source In response, the Thai government has demonstrated regulatory agility and sustained commitment. In 2004, for example, a cabinet directive prohibited tobacco company interference with policymaking, including a ban on material contributions to public officials.^source

As the Thailand experience demonstrates, the fight against tobacco is a fight against Big Tobacco: a savvy, relentless, enemy whose profits depend on developing, manufacturing, and marketing products that cause ill health and death.

As one of the first low- and middle-income countries to take tobacco control seriously, Thailand was also among the first to confront transnational tobacco companies. Thailand has shown that, with sustained political commitment, aggressive tobacco control measures can substantially reduce the prevalence of tobacco. It has also demonstrated the need for constant vigilance. Governments must recognize tobacco control is a long-term fight and successful antismoking measures require adaptability, constant monitoring, and an aggressive defense strategy.

Thailand's approach to tobacco control may have implications for other leading drivers of noncommunicable disease. One obvious candidate is alcohol, an important risk factor for liver disease, cardiovascular problems, and cancer.^source Many staples of Thailand’s tobacco control program—such as high taxation, health warnings, and advertising bans—could be applied to alcohol.

Other countries should look to Thailand for inspiration, both to identify concrete measures to fight 21st century vices and as a shining example of sustained political will to improve citizens’ health.