I see a great opportunity for us. You won’t believe this, but I’m at a public health conference in Sousse in Tunisia. I’ve come with my twin brother, a professor of public health. I am, of course, incognito. My brother asked me—yes, asked me—to come. Despite what you might think, we agree on most things—but differ radically on tobacco. We are twins, our connection goes deep. He hoped that by getting me to come to this conference he might get me to change my views. Unfortunately for him—and we’ve discussed this—the effect has been the opposite: I see a huge chance to grow our business.
The slide that hit me was put up by a charming—and clearly very intelligent—man from the World Health Organization. It showed smoking rates in men and women for all the countries of the WHO Eastern Mediterranean Regional Office (EMRO). This is some region, including almost all the countries affected by war—Somalia, Sudan, Palestine, Syria, Iraq, Afghanistan, and Pakistan. What hits you first about the slide is that most men in these countries smoke, but very few women. This is for cultural reasons. There is a strong stigma against women smoking. But what hits you next is there is one country in the region, Lebanon, where women (39%) smoke almost as much as men (48%). If that can happen in Lebanon, why not in all the countries of EMRO (and beyond)?
Fascinated by the idea and the prospects, when I got back to my hotel (where a satisfying number of Europeans are smoking outside the restaurant) I did some more digging. What, I wondered, is happening among the young? The results were gratifying. Lebanon again leads the way with 54% of girls aged 13-15 using a tobacco product compared with a magnificent 66% of boys. But girls in many countries in the region are doing well: Palestine West Bank (28%), Iran (20%), Syria (19%), UAE (13%). Things are moving our way. Tunisia itself is sadly not so good with only 4% of girls using tobacco, but some cocky Brit at the meeting asked whether people were worried about girls and women beginning to smoke at the same rate as boys and men—and, of course, they are. So they should be.
I heard other stories that pleased me. At one point in Tunisia an Islamic Party wanted to restrict the rights of women. The women mobilised and stopped the move dead. Women are more powerful in Tunisia than in most Moslem countries. Why, I asked myself, should they not be able to smoke just like men? Then a doctor told me it’s culturally unacceptable to ask women in Tunisia if they smoke, although it’s clear that some of them do and have been doing so for a long time. (This means, of course, that the prevalence rates among girls and women are probably underestimates.) I’m not sure if this is true in Tunisia, but friends in other strict Moslem (and Tunisia is one of the most liberal) countries have told me that what goes on beyond some closed doors far exceeds the licentiousness of what happens in Europe and the United States.
So my judgement is that the market looks very favourable to us. It may well be that our revenues will grow without us having to do anything much, but we must surely be more energetic. We must also be subtle. You are the experts, but don’t you think that what has worked in the West (where, pleasingly, smoking rates among girls often exceed those of boys) will work in this region? We must associate smoking with strength, glamour, ambition, progress, achievement, and above all freedom. What about: “Only the free can smoke” or “Work hard, smoke hard”? You will do better. And what might be our means? Television advertising is both expensive and old fashioned. Surely we can use social media, and what about personal networks? Could we use personal networks, perhaps a network like the old fashioned Avon ladies? The public health people in some countries use hairdressers. Why not us too? We can offer them much more than the public health people can. I’m sure that most of the promotion must come from women, local women.
Here’s an outrageous thought, but what about targeting female doctors and medical students? They live stressed lives but aspire to more freedom. We know that in many EMRO countries doctors have high rates of smoking. Increasingly doctors are women. This would be a masterstroke, not only providing perfect role models but also muting opposition.
I’m getting beyond myself. Don’t worry about my wild ideas, just do what you need to do to get smoking rates among women as close as possible to men in all these countries. I will be asking our “numbers guys” to set annual targets. I saw at the meeting that WHO has set a global target for reducing smoking rates by 30% by 2025 and is now urging countries to set their own targets. They want to reduce smoking. We want to do the opposite. Their numbers are broad, plucked out of the air it seemed to me, while ours will be based on solid analysis and will be annual. We will incentivise local managers to reach the targets.
And you don’t need me to remind you that the really big prizes are to be found not in the EMRO region, but in China, India, and the other big countries. My mouth waters whenever I’m in Beijing, where, as you know, 45-50% of men smoke but only 2% of women. The women I see in Beijing look very similar to me to the women I see in New York—fashionable clothes, enjoying parties, and out and about anywhere. We’re talking about a new market of around 800 million. Make it happen, and you will be well rewarded.
I must go to more public health meetings. They are a rich source of ideas, and I can’t help noticing that the people at the meetings feel misunderstood, neglected, and under-resourced. They are the poor relatives of medicine. We can walk all over them with ease.
Richard Smith was the editor of The BMJ until 2004. He is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh], and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.
Competing interest: RS is the director of the UnitedHealth Chronic Disease Initiative, which has funded the research in Tunisia and at least in part the meeting. He spoke at the meeting, and the UnitedHealth Foundation has funded the work he presented.