10.1 Tobacco

10.1 Tobacco
Oxford Textbook of Public Health

Samara Asma, Gonghuan Yang, Jonathan Samet, Gary Giovino, Douglas W. Bettcher, A.D. Lopez, and Derek Yach

The tobacco epidemic
Epidemiological model of tobacco use and dependence
Characteristics of the tobacco epidemic
History, structure, and conduct of the multinational tobacco industry
The global corporate actors
Decades of deceit
The tobacco industry’s public promises
The tobacco industry’s public denials of the health hazards of smoking
The tobacco industry’s internal acknowledgement that smoking causes disease
The tobacco industry’s stance on addiction
The tobacco industry’s manipulation of nicotine
The tobacco industry’s targeting of youth
The tobacco industry’s global strategies
Tobacco control
Components of a comprehensive strategy
Chapter References

Tobacco use is unique in terms of its current and projected future impacts on global mortality. If current trends continue, the number of people killed by tobacco use will more than triple to 10 million annually by the year 2020 (Murray and Lopez 1996). Despite this impending danger, there is also an opportunity—a lag between the precursors of the epidemic and its projection. While high smoking rates among men are nearly universal, the same is not true for women and children. Moreover, multiple disclosures of industry documents have had a significant impact in providing new information about the history and conduct of the tobacco industry. These documents have changed the way in which we perceive the tobacco debate (Bettcher and Yach 1998, 1999). Thus, in the face of the unprecedented toll caused by tobacco use and the worrying projections, there is also an opportunity to learn and apply vital lessons for the future of world health.
The purpose of this chapter is to explore that opportunity by (a) examining the history of tobacco use and dependence, and the current and projected pattern of the tobacco epidemic, (b) reviewing the structure, conduct, and strategies of the tobacco industry, and (c) proposing dynamic tobacco control strategies, already proven to be effective in some countries, which may have relevance throughout the world.
The tobacco epidemic
In this section we review the history of tobacco use and dependence, the epidemiological model, and the characteristics of the tobacco epidemic. The characteristics of the epidemic include production of tobacco, patterns of tobacco use, cessation, nicotine dependence, exposure to environmental tobacco smoke (ETS), and the burden of tobacco-related diseases.
The tobacco plant (Nicotiana tabacum) originates from South America, where tobacco habits were practised for ceremonial and shamanistic purposes long before Columbus arrived; however, it was not consumed regularly. By the arrival of Columbus in 1492, tobacco was being chewed, smoked, or snuffed in many areas of both North and South America. In the 1700s and the early 1800s, large quantities of tobacco were being snuffed by the aristocracy of Europe and chewed by the American settlers. By the middle of the 1800s the technology for making cigarettes and flue-curing tobacco had been developed, and the chewing of tobacco was beginning to be considered unhygienic. The converging development of several technologies between the late nineteenth and early twentieth centuries made the modern cigarette possible. New tobacco blends and curing processes were developed, which produced a tobacco product that, when burned, could be inhaled. Machinery for manufacturing cigarettes cheaply was perfected, the safety match was invented, and advertising and promotion techniques promoted the products of the tobacco industry. By the time of the First World War the mass production of cigarettes had begun and smoking among men in industrial countries began to rise dramatically. Cigarette smoking became increasingly accepted among women in industrial countries, starting about the time of the Second World War. At this time, smoking also began to rise in men in developing countries. Today, tobacco is cultivated commercially in more than 120 countries and is consumed in all countries of the world (Gold 1995).
Epidemiological model of tobacco use and dependence
The traditional epidemiological model of agent, host, vector, and environment facilitates the understanding of factors that influence patterns, determinants, and consequences of tobacco use (Orleans and Slade 1993).
An agent is traditionally defined as a factor whose presence is essential for the occurrence of disease (Last 1995). In this model, the myriad components of tobacco and tobacco smoke cause disease. Tobacco and tobacco smoke contain over 40 000 chemicals, including hundreds that are toxic or carcinogenic (USDHHS 1989; Hecht 1999). Tobacco also contains nicotine, an addictive compound that serves to maintain people’s use of the agent even when they want to quit (USDHHS 1988; Giovino et al. 1995; FDA 1996). The bioavailability of nicotine can be influenced by the pH of the product (FDA 1996; Fant et al. 1999). In the United States, many tobacco products (e.g. so-called ‘low tar’ cigarettes) may appear to be less dangerous than others on the basis of ‘tar’ and ‘nicotine’ ratings derived from a smoking machine. However, such products are rated by a machine testing system that does not represent the way that smokers compensate for reduced nicotine yield, and their availability may undermine smokers’ motivations to quit (USDHSS 1996; Kozlowski et al. 1998a,b).
The host in this model is the person who uses the product, i.e. one who smokes tobacco (through a cigarette, cigar, pipe, or other smoking device), chews or dips oral tobacco, or inhales snuff. Host factors found to be determinants of smoking include demographic characteristics, knowledge, attitudes, and behaviours, tobacco use by friends and family members, and susceptibility to addiction and disease (USDHHS 1989, 1994). One significant challenge to tobacco control lies in understanding why some people who experiment with smoking easily discontinue whereas others progress to become regular dependent users. Host factors can influence why some dependent smokers quit and others continue, and why some lifelong smokers develop smoking-attributable diseases while others do not.
Because ETS (the combination of sidestream smoke and exhaled mainstream smoke inhaled by non-smokers) causes disease in many exposed persons who do not consume tobacco products (USDHHS 1986; California Environmental Protection Agency 1997; SCOTH 1998; Samet and Wang 2000), the complete disease model also includes involuntary smokers as incidental hosts (DiFranza and Lew 1995). The vector serves to transport the agent to susceptible individuals (Last 1995). Just as we need to understand, for example, the role of the rat in the spread of the plague or the mosquito in the spread of malaria, we need to understand that tobacco has a vector—tobacco manufacturers. Thus, in the development of nicotine addiction and tobacco-attributable disease, tobacco manufacturers produce the agent and distribute it in ways that make the product appealing to both users and non-users. The industry uses packaging, advertising, and promotion to reach and influence as many people as possible. The price of the product (the lower the price, the more will be sold) and the ease with which it can be obtained (from vending machines, over-the-counter displays, and sales by street vendors) are also key distribution factors. In the case of tobacco, the vector also serves to undermine public health attempts to limit use by denying for decades the health consequences of use, and resisting many health-promoting programmes and policies (Hilts 1996; Kluger 1996; Jamieson 1998). This vector actively markets products that tacitly claim to be less hazardous, while simultaneously denying that any of their products cause disease and death (USDHHS 1996; Leavell 1999). Additionally, for decades the vector has manipulated the product in ways that have made it more addictive and potentially more harmful. For example, by the manipulation of pH, manufacturers have enhanced the bioavailability of nicotine to the smoker (FDA 1996; Hurt and Robertson 1998).
The environment includes diverse cultural, historical, economic, and political factors. In many countries, tobacco growing and tobacco product manufacturing have been, for decades, respected and lucrative businesses that wielded tremendous economic and political influence (World Bank 1999). When the health effects became known, and more recently when the industry’s malfeasant activities became apparent, attitudes towards the industry changed precipitously. Nevertheless, the powerful effects of pro-tobacco forces have influenced many political decisions (Kluger 1996; Jamieson 1998). In addition, the industry often attempts to gain cultural and political favour by sponsoring cultural events and promoting smoking prevention campaigns (Tobacco Institute 1991; USDHHS 1998; Charleston Gazette 1999). Economic and cultural influences in regions where tobacco is grown and/or where tobacco products are produced often result in reduced support for tobacco control activities. Environmental factors also include efforts by the tobacco control community to counter pro-tobacco influences.
This model has proved useful for both research and intervention. Past and ongoing research addresses each of the components of this model, as well as the interactions among its elements. Most research has focused on host factors, although more recent attention has also turned to policy factors. With the widespread dissemination of industry documents, our understanding of the vector has increased.
Interventions address different levels in a continuum that extends from the individual smoker to the national and international levels. Some attempt to influence host factors, for example by educating people about the dangers of tobacco use, how to quit, and ways to resist pro-tobacco influences from the peers and the media. Recent activities attempt to influence the environment, for example by promoting policy changes and mass media interventions. The industry is changing the agent, for example by developing nicotine-delivery products that heat (as opposed to burn) tobacco. Regulatory efforts strive to control both the agent and the activities of the vector.
Characteristics of the tobacco epidemic
In this section we aim to provide an overview of the characteristics of the global tobacco epidemic, which will include tobacco production and its patterns of use. It will also describe tobacco use cessation and nicotine dependence, and discuss the exposure to ETS. Finally, it will conclude with a review of the literature of the patterns and burden of tobacco-related diseases.
Tobacco production
In this section we classify and describe the various tobacco products available, tobacco growing, and the world market in manufactured tobacco products.
Types of tobacco products
There are two main forms of tobacco in common use: smoking tobacco and smokeless tobacco. Smoking tobacco includes manufactured cigarettes (filter and unfiltered) and ‘roll-your-own’ cigarettes. Kretek (clove-flavoured cigarettes), from Indonesia, are sticks made from a local variety of sun-cured tobacco known as brus and wrapped in cigarette paper. Bidis (small hand-rolled cigarettes consisting of sun-dried tobacco wrapped in a tendu leaf) are smoked throughout Southeast Asia, particularly in India. Cigars are made of air-cured and fermented tobacco with a tobacco leaf wrapper, and come in many shapes and sizes, from cigarette-sized to 10-g double coronas. Pipes are used predominantly in Europe, the Americas, and Southeast Asia; for example, clay pipes known as sulpa, chilum, and hookli are common in Asia. Water pipes, also known as hookah, gaza, narghile, hubble-bubble, and shisha, are in common use in North Africa, eastern Mediterranean countries, and parts of Asia.
Smokeless tobacco products, consisting of tobacco leaf and a wide variety of flavouring and other ingredients, are used either orally or nasally. Smokeless tobacco includes chewing tobacco, used in Western Europe and North Africa, and snuff (dry and moist snuff). Chewing tobacco is produced by shredding tobacco leaf. The leaf can be consumed loosely, or by pressing into bricks (plugs), or by drying and forming twist. Snuff, which may be sniffed or placed in the mouth, has a much finer consistency than chewing tobacco and is made from powdered or finely cut tobacco leaves. Chewing tobacco is prevalent in the Eastern Mediterranean and South Asia. Moist snuff taken orally has been used for many years in Sweden and the United States. Smokeless tobacco is being actively marketed as a popular form of tobacco among children and adolescents in Canada, the United States (including Alaska), Scandinavia, and the United Kingdom (Peterson et al. 1990).
Tobacco growing
Tobacco is grown in more than 120 countries. In 1994, over 5 million metric tons of tobacco (dry weight) were produced worldwide (WHO 1997a), and by 1997 leaf production had increased to 8 million metric tons, up 25.9 per cent in 3 years (Table 1) (World Bank 1999). China is the world’s leading producer of tobacco, with production increasing from 2.1 million metric tons in 1994 (36.3 per cent of total world output) to 2.4 million metric tons in 1997 (42.1 per cent of total world output). In 1997, the other seven leading producers were the United States, India, Brazil, Turkey, Zimbabwe, Indonesia, and Malawi.

Table 1 Output of tobacco leaf by world’s 25 leading producers

Manufactured tobacco products
Although tobacco is mainly grown in developing countries, the world market is dominated by a handful of American, British, and Japanese companies, which have a controlling presence not only in all Western countries but throughout the developing world. China is an exception, with its tobacco products mainly used in the domestic market. About 5.5 trillion cigarettes were manufactured worldwide in 1994; four countries (China, the United States, Japan, and Germany) accounted for over half of global production (WHO 1997a).
During the late 1990s, two major trends emerged which were significant for the future of the tobacco industry. First, the multinationals merged into a few major conglomerates. Second, state monopolies were increasingly privatized and merged with multinationals. The international cigarette market has recently undergone a significant structural change: British American Tobacco (BAT) acquired Rothmans, Japan Tobacco purchased RJR Tobacco International (RJRTI), and France’s Seita merged with Spain’s Tabacalera to form Altadis. In 1998, Philip Morris’s worldwide volume totalled 945 billion cigarettes (units), BAT–Rothmans volume stood at 922 billion units, and JT–RJRTI produced 451 billion units. These three companies controlled 65 per cent of the 3.8 trillion units that were sold outside of the People’s Republic of China (Goldman 1999). Altadis has become the top producer of cigars, with a global market share of 24.7 per cent in 1998, while its cigarette wing showed a volume of 106 billion units (Seita 1999).
In some countries, state-owned tobacco companies continue to dominate within their own market; the most notable of these is the China National Tobacco Corporation, which is the largest tobacco company in the world in terms of number of cigarettes sold (WHO 1999a). Increasingly, however, the multinationals are moving into countries formerly controlled by state monopolies and introducing aggressive marketing programmes. For example, in the 1980s the American tobacco companies relied upon the United States government—and the threat of trade sanctions—to open the cigarette markets in Japan, Taiwan, South Korea, and Thailand (Chaloupka and Corbett 1998). The shift in focus of the multinationals also comes at a time when they are under increasing attack in their home bases, particularly in the United States, as new disclosures become public detailing how the tobacco industry built and maintained its markets in the United States through decades of improper conduct. These disclosures, in addition to shedding important historical light on the tobacco industry, also provide sobering and relevant insights as the tobacco industry expands to conquer new markets.
Patterns of tobacco use
The continuum of tobacco use in a smoker’s lifetime can be described in terms of five stages: pre-contemplation, contemplation, preparation, action, and maintenance (Prochaska et al. 1997). These dynamic processes are major contributors to a given population’s patterns of tobacco use. (Differential mortality and immigration also contribute to a country’s patterns of use, but to a lesser extent.)
Although the prevalence of smoking has decreased and quitting rates have increased in some developed countries in recent decades, the overall global pattern of tobacco consumption is of major public health concern. In 1995, nearly 1.1 billion people smoked cigarettes (including bidis), consuming a total of 5 trillion cigarettes. The current smoking rate for the world’s population is 29 per cent: 47 per cent among males and 12 per cent among females. In developed countries, the prevalence of smoking for males and females is 39 per cent and 24 per cent respectively. In developing countries, the gender difference in smoking prevalence is larger, with 49 per cent of males and 7 per cent of females smoking (WHO 1997a).
The difference in smoking prevalence among regions is great, especially among women. The highest prevalence of smoking is 60 per cent in males in the Western Pacific Region; about 30 to 40 per cent of males smoke in other regions. The highest prevalence of smoking in females is in the Americas and Europe where over 20 per cent of women are regular smokers. In the Asian and Eastern Mediterranean regions the prevalence of smoking in females is lower, at about 4 per cent (WHO 1997a).
The prevalence of tobacco use by gender is shown for 87 countries in the report Tobacco or Health: A Global Status Report (WHO 1997a). Male smoking prevalence is 50 per cent or more in 22 countries and 60 per cent or more in eight countries: the Republic of Korea, China, Latvia, the Russian Federation, the Dominican Republic, Tonga, Turkey, and Bangladesh. The prevalence of smoking is lower (35 per cent or less) in Western and Northern European countries, North America, Australia, New Zealand, and Singapore. Female smoking prevalence is 25 per cent or more in 26 countries and 30 per cent or more in six countries: Denmark, Norway, the Czech Republic, Fiji, Israel, and the Russian Federation. Three countries—Fiji, Poland, and the Russian Federation—rank in the top 20 for both male and female smoking prevalence.
Trends in the consumption of tobacco
The global and regional trends in cigarette consumption per adult aged 15 years and over in 1970–1972 and 1990–1992 are given in Table 2.

Table 2 Annual consumption of cigarettes per adult (15 years and over) between 1970–1972 and 1990–1992, by region

Trends in consumption rates have varied worldwide. Overall, the world has seen an average annual increase of approximately 1 per cent in adult per capita consumption over the last two decades. The most rapid declines have been in countries such as Canada and the United Kingdom, where average annual decreases of 1.8 per cent and 1.6 per cent respectively have been recorded since the early 1970s. These have not been matched by equivalent declines in prevalence.
In contrast, over the same time period there have dramatic average annual increases in China (8 per cent), Indonesia (6.8 per cent), Syria (5.5 per cent), and Bangladesh (4.7 per cent). These high rates of increase are occurring from a low starting base, but China and Syria have already reached the per capita consumption levels of the United Kingdom and in both countries the rates of smoking among women remain low. There is growing concern about the efforts of the tobacco industry to increase smoking rates among women in developing countries (WHO 1997a).
In many countries, people begin smoking at young ages, with the median age of initiation usually being under 15 years. The prevalence of smoking in youth continues to increase in both developed and developing countries, even where the overall prevalence of tobacco use is declining (WHO 1997b).
In the United States, 1 226 000 persons aged under 18 years became daily smokers (smoking every day) in 1996 (CDC 1998). Data from the 1997 United States Youth Risk Behavior Survey indicate that the prevalence of current cigarette smoking among American high-school students increased from 27.5 per cent in 1991 to 36.4 per cent in 1997. In 1997, 42.7 per cent of high-school students had used cigarettes, smokeless tobacco, or cigars during the 30 days preceding the survey (CDC 1998).
In China, the regular smoking rate (proportion of people who smoked at least one cigarette daily among the whole population) in 1996 was 31 per cent—an increase of 3.4 per cent compared with 1984. Between the two surveys, the ages at which males and females reported starting to smoke dropped by about 3 years. For men, the average age of starting smoking in the 1996 data was about 19 years compared with about 22 years in 1984. For women, the age of starting to smoke dropped from 28 years of age to 25 years between the surveys (Yang 1997).
Many studies have shown that sociodemographic, environmental, behavioural, and personal factors are associated with the onset of tobacco use. Environmental factors include availability and advertising of cigarettes, the perception that tobacco use is the norm, peer and sibling attitudes, and lack of parental support during adolescence (Reid et al. 1995). Availability and ease of acquiring cigarettes are also environmental factors that can have an impact on smoking among adolescents. Parental attitudes toward smoking, and in particular towards their own children’s smoking, has been shown to be related to adolescent smoking. Also important are school performance and psychosocial factors, including low academic achievement, rebelliousness, low self-esteem, alienation from school, and lack of skills to resist offers of cigarettes (Tyas and Pederson 1998). These findings are mainly from Western countries (Conrad et al. 1992; Tyas and Pederson 1998); a few studies from developing countries such as China have shown similar results (Zhu et al. 1996; S.Q. Wang et al. 1994).
Tobacco use by women
Tobacco use is one of the major causes of premature disease and death, and is an emerging global public health problem especially among girls and women. According to the World Health Organization (WHO), currently more than 200 million women smoke cigarettes worldwide and this figure excludes those using other forms of tobacco. It is estimated that between 80 000 and 100 000 young people start smoking everyday, and many of these are girls. An estimated 12 per cent of women smoke globally; about 24 per cent of women smoke in developed countries, while 7 per cent of women smoke in developing countries (WHO 1997a). Again, these statistics do not include forms of tobacco use other than cigarettes. For example, in India 75 per cent of men and only 10 per cent of women smoke. The prevalence of other forms of tobacco use, i.e. chewing tobacco, ranges from 15 to 67 per cent (Gupta 1996). Historically, smoking has been more common among men than among women in the majority of countries. In countries for which reliable data are available for assessing trends in smoking (primarily industrialized countries), peak prevalence among women occurred some years after it did so for men (Pierce et al. 1991). While there are minor gender differences in smoking rates in some industrialized countries (such as the United States, New Zealand, and Australia), disparities between male and female smoking rates in Asia are striking, specifically in Japan (61 per cent of men and 15 per cent of women), Korea (70 per cent of men and 5 per cent of women), and China (61 per cent of men 7 per cent of women).
Rates are also rising among young women in many countries in Asia and the Pacific regions, where smoking is a symbol of women’s liberation and freedom from traditional gender roles. There is an even greater cause for alarm because statistics on cigarette consumption do not reflect the widespread use of smokeless tobacco among women in South Asia. For example, in Kerala, India, 22 per cent of rural women chew tobacco in a betel leaf. In the Bihar region and parts of Punjab and Harayana, women also smoke bidis and hookahs,. Rural Indian women in the state of Goa rub and plug burnt powdered tobacco inside their mouths (Aghi et al. 2001). It would be a major public health setback if women in all developing countries begin to smoke like women in developed countries and continued to use other forms of tobacco.
One of the contributing factors to this rising epidemic of tobacco use among women is the proliferation of seductive tobacco advertising worldwide which may lead women and girls to believe that smoking is socially desirable behaviour. Typically, women’s brands in the developing countries feature slim glamorous Western models. Such models lend a sense of foreignness to the cigarette and can serve as symbols of prestige and modernity. To sell such images, tobacco companies in the United States spend in excess of US$5 billion annually on marketing and promotion. Japan will account for 56 per cent of spending in Asia and the Pacific region in 1999. In recent years, transnational tobacco companies have increasingly turned their focus to the developing world, with intensive marketing campaigns aimed at women and girls.
The Kobe Declaration adopted in 1999 by women and youth leaders, scientists and policy-makers ‘demanded a global ban on direct and indirect advertising, promotion and sponsorship by the tobacco industry across all media and in all forms of entertainment; and demanded public funding for counter-advertising that disconnects women’s liberation and tobacco use and that reaches women and girls in all cultural contexts’ (WHO 1999a).
Tobacco use and indigenous people
Tobacco use is an important factor that impacts negatively on the health of indigenous peoples who have the highest rates of tobacco use in the world. It is not unusual for the rates of smoking of indigenous peoples to be twice that of the general population of the country in which they live. A survey among the Inuit of Greenland found that currently 82 per cent of Inuit men and 78 per cent of Inuit women are smokers. Further, in the area of Disko Bay, approximately 65 per cent of pregnant women were smokers (AMAP 1998). Therefore it is not surprising that the incidence and mortality of tobacco-related cancers are very high among the Inuit of Greenland (AMAP 1998). Similar patterns of smoking and smoking-related disease are evident among other groups of indigenous peoples, including the Maori of New Zealand, the First Nations and Inuit peoples of Canada, and the Aborigines and Torres Strait Islanders of Australia. By 1993, the rate of smoking among the Maori of New Zealand (46 per cent of Maori aged 15 years and over) was twice the rate of non-Maori New Zealanders. The rate for Maori women at this time was 58 per cent, with survey findings indicating that approximately 69 per cent smoke during pregnancy (Durie 1998). In 1997, 62 per cent of First Nations and Labrador Inuit adults (aged 15 years and over) were smokers. The ratio for indigenous and non-indigenous peoples of the Northwest Territories in 1996 was similar (S. Gauthier, unpublished report, 1999). The Aborigines and Torres Strait Islanders of Australia have twice the rate of smoking of the non-indigenous Australian population (54 per cent of indigenous men and 46 per cent of indigenous women, compared with 28 per cent and 22 per cent of non-indigenous men and women respectively (Australian Bureau of Statistics and the Australian Institute of Health and Welfare 1997).
Given the high level of tobacco use by many indigenous peoples around the world, it is essential that their distinctive needs are not lost in national and global public health efforts to control the tobacco epidemic. Tobacco control among indigenous peoples is not adequately addressed within the framework of minority groups or vulnerable populations. Specific approaches are needed to address their distinctive tobacco control needs.
Smoking cessation and nicotine dependence
Smoking cessation decreases health risks, even at older ages (USDHHS 1990). However, many smokers try to quit but fail. Nicotine dependence is the major reason for relapse after quitting. Nicotine, an alkaloid, is a constituent of all tobacco products and a drug that leads to addiction (USDHHS 1988). Nicotine administration can lead to tolerance and physiological dependence. Tolerance is indicated by the diminished response to repeated doses of nicotine. Nicotine-induced physiological dependence and withdrawal are specific to the administration or removal of nicotine itself. Cessation from tobacco following chronic use results in withdrawal symptoms, including a craving for nicotine, impaired ability to concentrate, disrupted cognitive performance, mood changes, and impaired brain function (Hatsukami et al. 1985).
Cessation of smoking is a dynamic process with a cyclical nature. Over the course of time, many people alternate between smoking and non-smoking. Smoking cessation is not a discrete process but rather a complex process involving several stages. The trans-theoretical model, which uses stages of changing to integrate processes and principles of change on people’s behaviour, conceives behavioural change as a process involving progress through a series of five stages: pre-contemplation, contemplation, preparation, action, and maintenance (Prochaska et al. 1997). Pre-contemplation is defined as a stage in which current smokers have no intention to give up smoking within the next 6 months. During contemplation current smokers intend to give up smoking within the next 6 months. Current smokers in the preparation stage are seriously preparing to give up smoking within the next 30 days and take some steps in this direction, such as reading relevant materials. The action stage is defined as the first 6 months after smokers stop smoking. Lastly, maintenance continues from 6 months after stopping smoking until the person is a confirmed non-smoker without relapse.
There may be different stage profiles of smoking cessation in different countries and different population groups. Understanding the different stage profile might help public health officials to design messages and projects targeted more appropriately. For example, results from the 1990 California Tobacco Survey of 12 815 smokers and ex-smokers aged 18 years and older showed that 27.4 per cent of the respondents were in the pre-contemplation stage, 34.3 per cent in the contemplation stage, 11.8 per cent in the preparation stage, 5.9 per cent in the action stage, and 20.7 per cent in maintenance (Kaplan et al. 1993). The stage profile of cessation is different in developing countries. The 1996 National Survey on Smoking Patterns in China reported that 63.9 per cent of smokers never intended to give up smoking and only 15.7 per cent of smokers intend to quit (Yang 1997).
Environmental tobacco smoke exposure
Non-smokers inhale ETS, the combination of sidestream smoke that is released as the cigarette burns and the mainstream smoke exhaled by the active smokers (First 1985). Exposure to ETS is difficult to measure accurately as it is not a direct consequence of actions by the exposed subject. Indicators of exposure to the ETS range from surrogate indicators to direct measurements of exposure and of biomarkers.
In some countries, in which male smoking prevalence exceeds female smoking prevalence, one useful index is the husband’s smoking status as an estimate of ETS exposure for wives. This is far from accurate because smoking by other family members may be important sources of ETS, the husband may smoke outside the home, and information about exposure before marriage is not captured (F.L. Wang et al. 1994). The indirect measures include self-reported exposure and description of the source of ETS in relevant microenvironments, most often the home and workplace, obtained by using questionnaires.
Nicotine and its metabolite cotinine have long been used as measures of tobacco smoke intake. The concentrations of serum and urinary cotinine in non-smokers increase significantly with the reported number of cigarettes smoked by their spouses; cotinine can be used to identify passive smokers and is sensitive to the extent of tobacco smoke exposure (Matsukura et al. 1984; Hackshaw 1998). However, cotinine provides a measurement for exposure within a few days and it cannot represent the long-term exposure to passive smoking.
The amount of ETS exposure of a non-smoker is influenced by the number of smokers in the indoor environment, the intensity of their smoking, the duration of exposure, the volume of the indoor environment, the ventilation characteristics, and the breathing pattern, as well as activity of the non-smoker (Samet et al. 1987). Homes, workplaces, and public places are all sources of ETS exposure, especially the home for women and children in many societies. The prevalence of ETS exposure can be very high, especially for women in countries where the prevalence of male smoking is very high. For example, in the survey of all current non-smokers in China in 1996, 54 per cent reported that they were exposed to ETS. The prevalence rate of ETS exposure in females (57 per cent) is higher than that in males (45 per cent). The highest exposure to ETS (up to 60 per cent) is in women of childbearing age, with higher exposure in the younger groups than in older age groups. The majority of passive smokers are exposed to ETS every day, with 71 per cent reporting exposure at home, 25.0 per cent reporting exposure in their work environments, and 33 per cent being exposed in public places.
Children’s exposure to ETS is involuntary, arising from smoking, mainly by adults, in the places where they live, work, and play. WHO estimates that about 700 million, or almost half, of the world’s children breathe air polluted by tobacco smoke, particularly at home (WHO 1999b). Data from a 1988 nation-wide survey of the United States show that about half of American children under the age of 5 years are exposed to tobacco smoke (Overpeck and Moss 1991). For more than a quarter of children, exposure begins before birth. Based on the survey data, 42 per cent of children in this age range were estimated to live in a household with a smoker. The proportion of ETS exposed children doubled from the highest income and maternal education groups to the lowest. In Shanghai, China, in the period 1986 to 1987, 58 per cent of newborn children were exposed to ETS, mainly from smoking by the father (Zhang and Ratcliffe 1993). For older children the proportion of ETS exposure ranges from 40 to 70 per cent (Overpeck and Moss 1991; Sherrill et al. 1992).
Patterns and burden of tobacco-related diseases
Toxicology of tobacco smoke
Tobacco smoke is generated by the burning of a complex organic material, tobacco, together with the various additives and paper, at a high temperature, reaching several thousand degrees Celsius. The resulting smoke, comprising numerous gases and also particles, includes many toxic components that can cause injury through inflammation and irritation, asphyxiation, carcinogenesis, and other mechanisms. Active smokers inhale mainstream smoke, i.e. the smoke that is drawn directly through the end of the cigarette. Passive smokers inhale smoke that is often referred to as ETS, comprising a mixture of mostly sidestream smoke, given off by the smouldering cigarette, and some exhaled mainstream smoke. Concentrations of ETS are far below the levels of mainstream smoke inhaled by the active smoker, but there are qualitative similarities between ETS and MS (USDHHS 1986).
Both active and passive smokers absorb tobacco smoke components through the lung’s airways and alveoli, and many of these components, such as the gas carbon monoxide, enter into circulation and are distributed generally in the body. There is also uptake of some components, such as benzo[a]pyrene, directly into the cells that line the upper airways and the lung’s airways. Some of the carcinogens undergo metabolic transformation into their active forms. The genitourinary system is exposed to toxins in tobacco smoke through the excretion of these compounds in the urine. The gastrointestinal tract is exposed through direct deposition of smoke in the upper airways and the clearance of smoke-containing mucus from the trachea through the glottis into the oesophagus. Not surprisingly, tobacco smoking has proved to be a cause of multisystem disease (USDHHS 1986).
There is a vast scientific literature on the mechanisms by which tobacco smoking causes disease (USDHHS 1989, 1994). This literature includes characterization of the many toxic components in smoke, which include well-known toxins such as hydrogen cyanide, carbon monoxide, and nitrogen oxides. The toxicity of smoke has been studied by exposing animals to tobacco smoke, in cellular and other laboratory toxicity assays, and by assessing smokers for evidence of injury by tobacco smoke using biomarkers such as tissue changes and levels of damaging enzymes and cytokines. The data from these studies amply document the powerful toxicity of tobacco smoke. For example, young smokers in their twenties already show evidence of permanent damage to the small airways of the lung (Niewoehner et al. 1974; PDAY Research Group 1990), and lavage of the lungs of smokers shows increased numbers of inflammatory cells and higher levels of markers of injury compared with non-smokers (USDHHS 1990). The new tools of molecular and cellular biologyhave provided evidence of tobacco-induced changes at the molecular level. For example, an activated tobacco-smoke carcinogen has been shown as binding to the same codon in the p53 gene where mutations are found in lung cancers in smokers (Denissenko et al. 1996) and a variety of genetic changes are found in epithelial cells in smokers’ lungs (Wistuba et al. 1997).
Review of evidence on health risks of active smoking
The most useful epidemiological studies for assessing the health risks of tobacco were the cohort studies initiated in the 1950s, 1960s, and 1970s, together with the follow-up mortality analyses pertaining to this period (Lopez 1999). All are limited to the study of mortality, and all give quantitatively similar results for the relative risks of smoking for various diseases (and all causes of death), despite the fact that the cohorts were recruited from countries as diverse as the United States, Sweden, Japan, Canada, and the United Kingdom. These findings have complemented the results of numerous case–control studies, some including thousands of cases (USDHHS 1989).
In the United States, the United Kingdom, and Canada, where men had been smoking in large numbers for decades before these studies were carried out, smoking was typically associated with 70 to 80 per cent excess mortality from all causes (Peto et al. 1996). The relative risks varied substantially by disease, and were largest for cancers of the lung and upper aerodigestive tract (mouth, pharynx, larynx, and oesophagus), and lowest for vascular diseases that have complex multicausal aetiology. Typically, lung cancer death rates were 10 to 12 times higher in smokers than in non-smokers, with the notable exception of Japanese men and American women for whom the relative excess was three to four times that of non-smokers. Similarly, the all-cause mortality ratios (relative risks) were substantially lower in these two studies, reflecting the fact that tobacco use in the two populations had been much lower than for other cohorts. Relative risks from lung cancer for American women smokers versus lifelong non-smokers increased from 2.7 in 1959–1965 to 11.9 in 1982–1986, reflecting the dominant role of duration of exposure in determining lung cancer hazards (USDHHS 1989).
Two large cohort studies have produced more recent evidence on health hazards from smoking, which have emphasized the increasing hazards of smoking with longer duration of use. These two studies are the 40-year follow-up of the 1951 British doctors cohort (Doll et al. 1994) and the second American Cancer Society Cancer Prevention Study (CPS-II) cohort of over 1.2 million adults monitored since 1982, for which comparisons can be made with CPS-I, initiated 20 years earlier (Thun et al. 1997).
The alarming size of the hazards observable in populations that have been smoking for many decades is now apparent. In the first 20 years of follow-up of the British doctors cohort (1951–1971), smokers had, on average, about a 1.5- to twofold higher death rate at each age, similar to the excess reported in other studies around that time (Doll et al. 1994). With a longer duration of smoking, the death rates of smokers increase substantially, so that during the second period of follow-up (1971–1991) the death rate of middle-aged smokers was three times higher than that of non-smokers (Doll et al. 1994). A similar excess mortality ratio was found in the second American Cancer Society Cancer Prevention Study (CPS-II) cohort based on follow-up in the latter half of the 1980s. These relative risks suggest that, on average, a smoker who begins smoking in young adult life and continues to smoke has at least a 50 per cent chance of eventually being killed by tobacco in either middle or old age (Peto et al. 1994).
The evidence from these two studies of the disease-specific risks associated with smoking is similar (Lopez 1999). Current smokers have about a 20-fold higher death rate from lung cancer than never-smokers, among whom lung cancer death rates have remained low and constant. There is epidemiological evidence to suggest that this is also the case in other populations. For example, based on the two American Cancer Society studies with follow-up to 1959–1965 and 1982–1986 respectively, lung cancer death rates among lifelong non-smokers were remarkably constant at 15.4 and 14.7 per 100 000 (age-standardized) for men, and 9.6 and 12.0 for women; the rates for current smokers were 187.1 and 341.3 for men, and 26.1 and 154.6 for women (Thun et al. 1997). Smokers also incur a 10- to 20-fold excess mortality from chronic obstructive lung disease (primarily chronic bronchitis and emphysema), and a risk of death from major vascular diseases that is about twice that of non-smokers.
The excess mortality of smokers from vascular disease is particularly noteworthy. Vascular disease death rates are typically much higher than those for cancer or other causes associated with smoking. Therefore cardiovascular diseases (especially ischaemic heart disease and stroke) contribute more to smoking-attributable deaths at a population level than other causes, including lung cancer for which the relative risk is much higher, although this pattern will change as cardiovascular disease mortality declines. Finally, it is worth noting that the all-age excess mortality ratio of about 2 from cardiovascular diseases masks a very significant age gradient in relative risks. At younger ages ({lt} 50 years), smokers have a five to six times higher death rate than non-smokers, with the relative excess declining with age. These data suggest that if a smoker dies from vascular disease before the age of about 50 years, there is a 70 to 80 per cent chance that death was caused by smoking, and that vascular disease is the chief mechanism through which smoking causes a threefold excess mortality rate in middle age (Parish et al. 1995).
Cigarette smoking is only one of several causative factors that produce disease. This is especially true for ischaemic heart disease where smoking interacts synergistically with other factors such as hypercholesterolaemia and hypertension to increase risk of heart disease substantially. Evidence suggests that the independent risk attributable to smoking is comparable with that of other major risk factors (USDHHS 1989). This interaction with dietary parameters probably explains the currently lower proportions of ischaemic heart disease attributable to smoking in populations such as China where low-fat diets have predominated (Liu et al. 1998).
Smoking by women also adversely affects reproduction. Smoking during pregnancy reduces birth weight by approximately 200 g on average (USDHHS 1990); the degree of reduction is dose-related. With successful cessation by the third trimester, much of the weight reduction can be avoided. Smoking also increases rates of spontaneous abortion, placenta previa, and perinatal mortality, and smoking during pregnancy is now considered to be a cause of sudden infant death syndrome. There is more limited evidence suggesting that smoking may increase childhood cancer incidence and congenital defects (Charlton 1996; SCOTH 1998).
Cigarettes have changed substantially over the last 50 years (USDHHS 1997). Filter cigarettes dominate the market, and tar and nicotine yields, as assessed by smoking machines, have declined substantially. Although tar and nicotine deliveries to smokers have little relationship to the machine levels (USDHHS 1997), epidemiological evidence comparing smokers of lower-delivery and higher-delivery products shows some reduction in risk for some cancers, particularly lung cancer, and for total mortality, but only a minor reduction for myocardial infarction (Peto et al. 1996; USDHHS 1997). Although rising relative risks of smoking have been documented across recent decades when the lower-delivery products came into widespread usage (Doll et al. 1994), this is due to a longer duration of exposure and not to a change in the hazard. For example, in the cohort study of British doctors, there was a substantial increase in mortality for smokers in the second 20 years of follow-up (Doll et al. 1994).
Health effects of passive smoking
Evidence on the health risks of passive smoking comes from epidemiological studies which have directly assessed the associations of ETS exposure with disease outcomes and also from knowledge of the components of ETS and their toxicities. Judgements as to the causality of association between ETS exposure and health outcomes are based not only on this epidemiological evidence, but also on the extensive evidence derived from epidemiological and toxicological investigation of active smoking. Additionally, studies using biomarkers of exposure and dose, including the nicotine metabolite cotinine and white cell adducts, document the absorption of ETS components by exposed non-smokers, adding to the plausibility of the observed associations of ETS with adverse effects.
ETS exposure of the infant and child has adverse effects on respiratory health, including increased risk for more severe lower respiratory infections, middle-ear disease, chronic respiratory symptoms, and asthma, and a reduction in the rate of lung function growth during childhood. There is more limited evidence suggesting that ETS exposure of the mother reduces birth weight and that child development and behaviour are adversely affected by parental smoking (Eskenazi and Castorina 1999; (WHO 1999b). There is no strong evidence at present that ETS exposure increases childhood cancer risk.
In adults, ETS exposure has been causally associated with lung cancer and may also increase the risk of ischaemic heart disease. The association of ETS with lung cancer has now been evaluated in about 40 epidemiological studies. The most recent meta-analysis combined evidence from 37 published studies, and estimated the excess lung cancer risk for smokers married to non-smokers as 24 per cent (95 per cent CI, 13–36 per cent) (Hackshaw et al. 1997). Since 1986, other expert groups have also found ETS to be a cause of lung cancer in non-smokers (EPA 1992; California Environmental Protection Agency 1997; Australian National Health and Medical Research Council 1997; SCOTH 1998). Coronary heart disease has also been causally associated with ETS exposure on the basis of observational and experimental evidence (Glantz and Parmley 1995; California Environmental Protection Agency 1997; SCOTH 1998), although this is a more difficult relationship to assess. A meta-analysis by Law et al. (1997) estimated the excess risk from ETS exposure as 30 per cent (95 per cent CI, 22–38 per cent) at age 65 years. There is also evidence linking ETS to other adverse effects in adults, including stroke (Bonita et al. 1999), exacerbation of asthma, reduced lung function, and respiratory symptoms, but the associations have not yet been judged to be causal (California Environmental Protection Agency 1997; SCOTH 1998; Samet and Wang 2000).
Quantifying population-attributable mortality due to cigarette smoking
Estimates of the population-attributable risk for a given risk factor or exposure in a defined population are generally calculated using the classical attributable risk formula which relates the prevalence of exposure to the relative risk of death from a specific cause for those exposed compared with those not exposed (Levin 1953). While this may be theoretically correct, the practical application of this approach will always be difficult as observed population prevalence for any population is not an adequate representation of population exposure corresponding to an observed set of relative risks. For example, current smoking prevalence does not include other critical aspects of exposure to tobacco smoke such as duration, amount, degree of inhalation, etc., all of which affect relative risks for disease. From the point of view of relative risks, even if one has reliable estimates of smoking prevalence for a population, to what set of relative risks should this ‘exposure’ variable be applied?
Peto et al. (1994) have proposed an indirect method of estimating smoking-attributable mortality, which circumvents these theoretical difficulties with the attributable-risk approach. Their method is based on the assumption that the excess lung cancer rate(over and above non-smoker rates) observed in a population is the best indicator of cumulative population exposure to smoking hazards. A ‘smoking-impact ratio’ (SIR) is calculated as the relative excess of lung cancer in the observed population compared with the observed excess of smokers over non-smokers, calculated from the CPS-II follow-up for 1984 to 1988. SIR is then used to scale the relative risks from CPS-II in order to apply them to other populations. To allow for confounding, and in an attempt not to exaggerate the hazards of smoking, these ‘scaled’ relative risks are then halved and applied to the national cause-of-death data for those populations (all developed countries) where the assumptions of the method might be reasonably applicable.
The method is crude and somewhat arbitrary, but validation against national studies using the classical attributable-risk approach suggests that the results obtained are not implausible (Valkonen and van Poppel 1997). The advantage of the method is that it yields annual estimates of deaths from smoking by age, sex, and cause which have been calculated for all developed countries for the period 1955 to 1995 and published elsewhere (Peto et al. 1994).
A summary of the levels and trends of smoking-attributable mortality estimated from the application of the Peto–Lopez method to mortality data for developed countries is given in Table 3 and Table 4.

Table 3 Estimated deaths caused by smoking in developed countries, 1950–2000

Table 4 Estimated percentage of deaths caused by smoking, sex, age, and major cause of death, all developed countries, 1995

Smoking is estimated to have been the cause of about 62 million deaths, mostly men (52 million) in the developed countries (Europe, including the former USSR, Australia, Japan, North America, and New Zealand) between 1950 and 2000. The annual mortality from smoking in the developed countries in 1995 was estimated to be about 1.9 million (1.44 million men and 0.48 million women), of which 1.2 million occurred in the established market economies and the remainder in the former socialist economies of Europe.
Estimates of current annual mortality from smoking in less developed regions are much more difficult to prepare, given the lack of representative and direct evidence from epidemiological studies on tobacco hazards. In view of the large background risks of lung cancer among non-smokers in many developing regions and the lack of reliable cause-of-death data, the Peto–Lopez method is not likely to be widely applicable in these countries without appropriate adjustment. The single exception is China where recent analyses of large retrospective and prospective evidence suggest that smoking is already killing about 800 000 people each year, mostly men (Liu et al. 1998). Data from a cohort study in Mumbai, India, found that all-cause mortality rates for smokers were higher than for non-smokers across all age groups in men and the difference was greater at younger ages. The relative risk was 1.39 for cigarette smokers and 1.78 for bidi smokers and there was a dose–response relationship. The relative risk among women in Mumbai, who were basically smokeless tobacco users, was 1.35. In this cohort, bidi smoking was as hazardous as cigarette smoking and smokeless tobacco also appeared to be related to excessive all-cause mortality (Gupta 1996).
Using a modification of the Peto–Lopez method, Murray and Lopez (1997a) have prepared estimates of smoking-attributable mortality for other developing regions. First, lung cancer mortality rates were estimated for each region, by age and sex, using methods reported elsewhere (Murray and Lopez 1997a). Next, the non-smoker lung cancer rates in each region were estimated on the basis of local epidemiological evidence, and the SIR in the Peto–Lopez method was adjusted (lowered) accordingly. These revised ‘scalars’ were then applied to estimated regional cause-of-death patterns in 1995 in the manner adopted by Peto et al. (1994).
To the extent that this method is reasonable for developing countries, smoking is estimated to cause about 1.6 million deaths each year in developing countries, half of them in China alone (Table 5). Most deaths in developing countries (1.4 million) occur among men, which is at least consistent with the sex differences in exposure described earlier. Annual mortality from smoking in developing countries is also much lower than in more developed regions, again a finding that is consistent with the observation that until recently cigarette consumption has been relatively low in much of the developing world. However, the pattern is changing rapidly. It is perhaps more relevant for public health to ask what the mortality will be in the future if current smoking trends persist than to estimate current smoking deaths (about 3.5 million) from past smoking levels. Based on projections of causes of death to 2020 and projections of lung cancer, Murray and Lopez (1997b) have estimated that smoking will cause about 8.4 million deaths annually by 2020, of which, on present trends, 6.0 million will occur in the developing world. Smoking is projected to be by far the leading cause of death in the world by the year 2020. A similar annual death toll has been forecast by Peto and Lopez (1990) using much cruder methods, with a prediction of 10 million deaths a year from smoking by about the late 2020s–early 2030s.

Table 5 Estimated number of deaths from tobacco by region, 1995

The tobacco epidemic undergoes four stages as it evolves within a country (Lopez et al. 1994). In the first stage, the prevalence of smoking among males is comparatively high, while among females it is low (about 15 per cent), which is largely because of sociocultural factors that discourage smoking among women. Death and disease due to smoking are not yet evident. In the second stage, the prevalence of smoking among men rises rapidly, reaching a peak of between 50 and 80 per cent. The proportion of ex-smokers is relatively low. Smoking prevalence among women typically lags behind that of males by 10 to 20 years, but increases rapidly. In the third stage, the prevalence of smoking among males begins to decline, falling to about 40 per cent by the end of this stage, which may last for several decades. The prevalence tends to be lower among middle-aged and older men, many of whom have become ex-smokers. Most importantly, the end of the third stage is characterized by an initial decline in smoking among females. There is also likely to be a marked age gradient in prevalence among women, with about 40 to 50 per cent of all young women being regular smokers but with relatively few smokers (about 10 per cent) among women above 55 to 60 years of age. Another characteristic of this period is the rapid increase in smoking-attributable mortality, which rises from about 10 per cent of all deaths in males to about 25 to 30 per cent within three decades. In middle age (35–69 years), the proportionate mortality of males due to tobacco is even higher (about one in three deaths). The tobacco-related death rate among women is still comparatively low (about 5 per cent of all deaths) but rising. In the fourth stage, smoking prevalence for both sexes continues to decline more or less in parallel, but only slowly, 20 to 40 years after reaching its peak.
History, structure, and conduct of the multinational tobacco industry
A distinguishing feature of the tobacco epidemic has been the role of major corporations—some of the largest in the world—in promoting smoking and, as a consequence, death and disease. This presents a unique challenge for the public health community. The adversary is not only disease or natural forces. It also includes powerful corporations whose actions are antithetical to public health as discussed earlier in the chapter.
As the twenty-first century begins, these transnational tobacco corporations are increasing their global markets. While total consumption of cigarettes is falling in high-income countries, consumption in low and middle-income countries is increasing (Taylor et al. 2000).
Given the growing influence of the multinationals, an understanding of their history, conduct, and behaviour is essential to help guide strategies for tobacco control. In the mid- to late-1990s, the public health community gained an unprecedented view of the tobacco industry through the release of millions of pages of previously secret internal tobacco company documents. These documents were obtained primarily through pre-trial proceedings in lawsuits against the tobacco industry in the United States. Accordingly, the term ‘industry’ is used in this chapter to refer to the defendants in the United States lawsuits, i.e. the main United States cigarette companies and the BAT group of companies based in the United Kingdom.
The global corporate actors
While tobacco in diverse forms has been used since antiquity, the modern cigarette did not become a popular phenomenon until the twentieth century. Until the late 1800s, cigarette production remained a cottage industry. Then came the mechanical cigarette rolling machine—called the Bonsack machine, after its inventor—to replace the hand-rolling of cigarettes. With a dramatically increased production capacity, the first of the major tobacco corporations, the American Tobacco Company, took control of the United States market, and the modern tobacco industry began to come of age.
Indeed, since the beginning of the twentieth century, much of the world’s cigarette market has been dominated by a handful of major corporations. In the early 1900s, the three major tobacco companies of the time agreed a pact to end their trade wars and to divide the world’s cigarette trade. American Tobacco was to limit its trade to the United States, its dependencies, and Cuba. The Imperial Tobacco Company of Great Britain and Ireland agreed to limit its trade to the United Kingdom. British American Tobacco (BAT) agreed to take over the export business of the other two companies and operate in other countries around the world (United States v. American Tobacco Co. (1911), 221 US 106).
Decades of deceit
In the mid- to-late 1990s, millions of pages of previously secret internal documents from the files of the American tobacco companies (and BAT in the United Kingdom) were publicly released in the United States. Most of these documents—some 35 million pages—were produced by the tobacco companies in litigation in the State of Minnesota pursuant to multiple court orders. The documents paint a damning picture of an industry which, for decades, suppressed scientific research and information on the health hazards and addictiveness of smoking, manipulated the amount and/or form of nicotine to exploit the addictive potential of tobacco, and targeted marketing campaigns at youth. In 1995, the Journal of the American Medical Association (JAMA) devoted an issue (Volume 274, pp. 219–53) to some of the first disclosures of tobacco company documents (which came from a legal assistant who apparently stole several thousand documents while working for a law firm retained by the tobacco industry). It was concluded that the documents ‘provide massive, detailed, and damning evidence of the tactics of the tobacco industry. They show us how this industry has managed to spread confusion by suppressing, manipulating, and distorting the scientific record’ (JAMA 1995). It was also stated that ‘analysis of these papers suggests that we would have seen a very different picture of tobacco use today if the group knowing the most about the dangers of tobacco use, the industry, had been honest with its customers … We can only speculate how many lives would have been saved and how much suffering would have been averted’ (JAMA 1995).
The tobacco company documents referred to in the following sections can be accessed at http://www.tobaccodocuments.org/ and http://www.tobaccoinstitute.com/documents.
The tobacco industry’s public promises
In the United States, the tobacco industry was forced to confront the issue of the health hazards of smoking publicly in the early 1950s. The first solid scientific evidence on the health hazards of smoking to receive widespread public notice were epidemiological studies and mouse-back painting experiments (where the backs of mice were painted with tar condensate from cigarettes) in the early 1950s (Doll and Hill 1950; Wynder and Graham 1950; Wynder et al. 1953). These studies generated widespread public concern about the health hazards of cigarettes. Confronted with this evidence, and this threat to their business, the presidents of the leading United States tobacco companies met at an extraordinary gathering in the Plaza Hotel in New York City on 15 December 1953. This was the beginning of a concerted industry-wide effort to deny the health hazards of smoking and cover-up the tobacco industry’s own knowledge of the hazards. The tobacco company executives who met at the Plaza Hotel in 1953 viewed the problem as a public relations problem and ‘as being extremely serious and worthy of drastic action’ (JH 000502).
The industry leaders felt ‘that the problem is one of promoting cigarettes and protecting them from these and other attacks that may be expected in the future’, and that the industry ‘should sponsor a public relations campaign which is positive in nature and is entirely“pro-cigarettes”’ (JH 000502).
On 4 January 1954, the tobacco industry took out full-page advertisements in every major newspaper in the United States. These advertisements were entitled ‘A Frank Statement to Smokers’ and stated (CTRMN 11309817):

We accept an interest in people’s health as a basic responsibility, paramount to every other consideration in our business.

We believe the products we make are not injurious to health.

We always have and always will cooperate closely with those whose task it is to safeguard the public health.
Over the years, the tobacco industry continued to renew the pledge set forth in the Frank Statement.
We in the tobacco industry recognize a special responsibility to help science determine the fact. (PM 1005136955)
In the interest of absolute objectivity, the tobacco industry has supported totally independent research efforts with completely non-restrictive funding…The findings are not secret. (Tobacco Institute 0081352)
If our product is harmful, we’ll stop making it. (RJR 500324163D)
Since the first questions were raised about smoking as a possible health factor, the tobacco industry has believed that the American people deserve objective, scientific answers. The industry has committed itself to this task. (B and W 670500618)
The tobacco industry’s public denials of the health hazards of smoking
Despite the pledges, year after year, decade after decade, the tobacco industry issued public statements creating doubt about the charges against cigarettes and denying that it has been proven that cigarettes cause any disease.
There is no demonstrated causal relationship between smoking and any disease. (B and W 670307882)
The deficiencies of the tobacco causation hypothesis and the need of much more research are becoming clearer to increasing numbers of research scientists. (RJR 500015902)
The flat assertion that smoking causes lung cancer and heart disease and that the case is proved is not supported by many of the world’s leading scientists. RJR 500184776)
In our opinion, the issue of smoking and lung cancer is not a closed case. It’s an open controversy. (RJR 504638051)
In fact, even as the twentieth century came to a close, some of the major players in the multinational tobacco industry refused to admit publicly that it had been proved that smoking causes any disease. In October 1999, Philip Morris publicly stated: ‘there is an overwhelming medical and scientific consensus that cigarette smoking causes lung cancer, heart disease, emphysema and other serious diseases in smokers’. At the same time, the company stated: ‘Cigarette smoking is addictive, as that term is most commonly used today’.
The tobacco industry’s internal acknowledgement that smoking causes disease
In striking contrast to the tobacco industry’s public statements, the newly disclosed internal tobacco company documents revealed that the tobacco industry had secretly acknowledged the health hazards of smoking. In fact, as early as 1958, most of the American industry apparently believed that smoking caused lung cancer. This was documented in a memorandum written in 1958 by three British scientists who visited the United States to meet top officials and scientists in the American tobacco industry. One object of their trip was to find out ‘the extent in which it is accepted that cigarette smoke“causes” lung cancer’. Upon completion of their trip, these British scientists reported widespread acceptance of causation. In their trip report, they wrote:
With one exception [an individual not affiliated with any tobacco company] the individuals with whom we met believed that smoking causes lung cancer if by ‘causation’ we mean any chain of events which leads finally to lung cancer and which involves smoking as an indispensable link. (BAT 105408490)
Some of the reasons for the tobacco industry’s refusal to admit publicly that smoking causes disease were set out in a document written in 1980 by a tobacco industry lawyer. The document was written at a time when the BAT companies were considering changing their public stance on the issue of causation. The lawyer opposed such a change, and wrote:
If we admit that smoking is harmful to ‘heavy’ smokers, do we not admit that BAT has killed a lot of people each year for a very long time? Moreover, if the evidence we have today is not significantly different from the evidence we had five years ago, might it not be argued that we have been wilfully killing our customers for this long period? Aside from the catastrophic civil damage and governmental regulation which would flow from such an admission, I foresee serious criminal liability problems. (B and W 680051009)
The tobacco industry’s stance on addiction
The tobacco industry has also repeatedly denied that cigarettes are addictive and minimized the difficulties of quitting smoking. For example, in a 1988 press release, the tobacco industry stated:
Claims that cigarettes are addictive contradict common sense… The claim that cigarette smoking causes physical dependence is simply an unproven attempt to find some way to differentiate smoking from other behaviors. (Tobacco Institute 0019963).
Once again, however, the internal documents show that the tobacco industry has long recognized that smoking is addictive. For example, a report of discussions with industry research directors in the 1950s, as the industry prepared to publish the Frank Statement, recorded among their conclusions: ‘it’s fortunate for us that cigarettes are a habit they can’t break’ (JH 000493). In 1961, a top industry scientist wrote: ‘smokers are nicotine addicts’ (BAT 30108362). In 1963, an industry lawyer wrote: ‘Nicotine is addictive. We are, then in the business of selling nicotine, an addictive drug(‘ (B and W 689033412). In 1969, another industry scientist wrote:
I would be more cautious in using the pharmic-medical model—do we really want to tout cigarette smoke as a drug? It is, of course, but there are dangerous F.D.A. [Food and Drug Administration] implications to having such conceptualizations go beyond these walls. (PM 1003289921).
In 1978, a tobacco executive wrote: ‘very few consumers are aware of the effects of nicotine, i.e. its addictive nature and that nicotine is a poison’ (B and W 665043966). In 1979, a tobacco executive considered the hypothesis that ‘high profits…associated with the tobacco industry are directly related to the fact that the consumer is dependent upon the product’ (BAT 109872505).
Again, one reason why the tobacco industry continued to deny publicly that smoking is addictive, despite these internal admissions, was to avoid legal accountability. As one internal document stated:
Shook, Hardy [long-established tobacco industry law firm] reminds us, I’m told, that the entire matter of addiction is the most potent weapon a prosecuting attorney can have in a lung cancer/cigarette case. (Tobacco Institute TIMN 0107822)
The tobacco industry’s manipulation of nicotine
The internal documents also demonstrate that the tobacco industry intentionally designed cigarettes to exploit their addictive potential. While nicotine is a naturally occurring component of the tobacco plant, the modern cigarette is a highly engineered and sophisticated product in both manufacture and design. Decades ago, the tobacco industry began to control and manipulate nicotine in cigarettes in a variety of ways.
The tobacco industry has the capability of removing virtually all of the nicotine from the manufactured cigarette. However, it designs cigarettes to ensure that nicotine levels fall within parameters such that a sufficient dose is maintained for pharmacological and addictive purposes. As early as 1959, the tobacco industry noted the need to find the ‘optimum offer’ of nicotine to consumers, recognizing that lowering nicotine too much ‘might end in destroying the nicotine habit in a large number of consumers and prevent it ever being acquired by new smokers’ (BAT 10009915). By 1963, one tobacco company noted that ‘Certainly, the nicotine level of Brown and Williamson cigarettes … was not obtained by accident’ and that ‘even now … we can regulate, fairly precisely, the nicotine and sugar levels to almost any desired level management might require’ (BAT 102630333). Another tobacco company referred to the ‘habituating level of nicotine’ and asked ‘how low can we go?’ (RJR 504210018). At another tobacco company, scientists wrote ‘we have shown that there are optimal cigarette nicotine deliveries for producing the most favorable physiological and behavioral responses’ (PM 2028813366).
Another method developed by the tobacco industry to enhance nicotine delivery was to manipulate the form of nicotine by controlling the pH of cigarette smoke through the use of ammonia compounds. The introduction of ammonia or ammonia compounds in the manufacturing process can raise the pH. As the pH rises, the smoke becomes more ‘basic’ and results in an increased amount of ‘free’ nicotine, also referred to as ‘free base’ nicotine in the tobacco company documents. Free nicotine is more volatile and physiologically active than bound nicotine. As one tobacco company document explained:
In essence, a cigarette is a system for delivery of nicotine to the smoker in an attractive, useful form. At ‘normal’ smoke pH, at or below about 6.0, essentially all of the smoke nicotine is chemically combined with acidic substances, hence is non-volatile and relatively slowly absorbed by the smoker. As the smoke pH increases above about 6.0, an increasing proportion of the total smoke nicotine occurs in ‘free’ form, which is volatile, rapidly absorbed by the smoker, and believed to be instantly perceived as the nicotine ‘kick’. (RJR 511223463)
Tobacco industry scientists ‘fully appreciated’ that the addictive potential of a drug, such as nicotine, is enhanced if it is delivered to the brain more quickly (Hurt and Robertson 1998). For example, one tobacco company document states that ‘free base nicotine is the most chemically and physiologically active form because it is most rapidly absorbed’ (BAT 500104402). Eventually, almost the entire United States tobacco industry used some form of ammonia technology in some of their brands (Hurt and Robertson 1998).
The tobacco industry’s targeting of youth
The tobacco industry is well aware of the fact that most smokers start smoking when they are young. In high-income countries, about eight of ten smokers begin smoking while in their teens. In low- and middle-income countries, most smokers start in their early twenties (World Bank 1999).
Publicly, the tobacco industry maintains that it does not want youth to smoke. However, the internal documents of the tobacco industry demonstrate that the tobacco industry has long recognized that the preservation of its market depends upon recruiting youth. As one document states:
Younger adult smokers are the only source of replacement smokers… If younger adults turn away from smoking, the industry must decline, just as a population which does not give birth will eventually dwindle. (RJR 501928462)
Thus the tobacco industry documents are replete with discussions of marketing to youth.
Evidence is now available to indicate that the 14 to 18 year old group is an increasing segment of the smoking population. RJR-T must soon establish a successful new brand in this market if our position in the industry is to be maintained over the long term. (RJR 501630269)
To ensure increased and longer-term growth for CAMEL FILTER, the brand must increase its share penetration among the 14–24 age group which have a new set of more liberal values and which represent tomorrow’s cigarette business. (RJR 505775557)
Kool’s stake in the 16–25 year old population is such that the value of this audience should be accurately weighted and reflected in current media programs. (B and W 170052238)
The base of our business is the high school student. (Lorillard 03537131)
Marlboro dominates in the 17 and younger age category, capturing over 50 per cent of this market. (PM 2043828174)
It is suggested to develop a new RJR youth-appeal brand … (RJR 501166152)
The tobacco industry’s global strategies
The documents also shed light on the tobacco industry’s global strategies and the industry’s conduct around the world. Certainly, the tobacco industry views the world from a global perspective. As one internal document stated in a discussion of why a global strategy was needed for the industry to combat tobacco control measures: ‘Experience tells us that no country is free from the influences of others in this area, and what is today’s restriction in Norway could become tomorrow’s in Malaysia’ (RJR 500629166).
The American tobacco industry worked to achieve a common strategy throughout the world. One R.J. Reynolds document stated:
It is recommended that RJR Tobacco International suggest to its overseas competitors that it would be beneficial for our Industry as a whole on a worldwide basis if a consensus could be developed on the Smoking and Health controversy… For historical reasons, the chief and earliest battleground for the Tobacco and Health controversy has been the United States. In the United States RJR Tobacco has more experience in this area than the other tobacco companies. We are therefore best equipped to take the initiative in trying to develop a common attitude among the various members of the worldwide cigarette manufacturing industries. (RJR 500950279)
The tobacco industry also set up a worldwide trade organization—known first as ICOSI and later as INFOTAB—to serve as an information clearing house and to ensure global co-ordination for the industry (B and W 681510625).
Another global strategy of the tobacco industry has been to attempt to thwart the tobacco control efforts of international agencies, such as the WHO. One document, in discussing the WHO, stated that:
This organization has extraordinary influence on government and consumers and we must find a way to diffuse this and re-orient their activities to their prescribed mandate. (PM 2021596422)
Another document discussed the need to counter WHO activities aimed at combating youth smoking. The document stated:
We need to identify the three countries in each region that the WHO will be targeting for special funding and muscle and, where it makes sense from a market standpoint, allocate the resources necessary to stop them in their tracks. We need … a well-developed strategy for a number of issues to which the WHO has given priority status. Examples include … juvenile smoking. (PM 2500103969)
As the multinational tobacco companies increasingly shift their attention to emerging markets, an understanding of the structure and behaviour of the tobacco industry becomes imperative as public health professionals attempt to fashion strategies to deal with a growing epidemic. These strategies cannot be formed and implemented in a vacuum. The tobacco industry is a major factor in the vector, and only by knowing its history and conduct—and taking measures to account for this—can public health strategies be effective. Thus a thorough understanding of the tobacco industry and its conduct will help tobacco-control efforts through regulation and legislation.
Tobacco control
The preventive potential for tobacco control to reverse the given forecast of a global tobacco epidemic is still high in many countries. We now have an improved understanding of the complexity of the tobacco epidemic, which will assist us to improve and activate interventions. The main focus of any strategy should be to prevent initiation of tobacco use, to promote quitting among the young and adults, and to eliminate non-smokers’ exposure to tobacco smoke. Cost-effective strategies are available and have already been proved to make a positive impact in many countries. To build on those successes, a comprehensive tobacco control strategy can provide a road map for national and global action. In this section we explore the key components of a comprehensive tobacco control strategy that is applicable locally, regionally, and globally.
Components of a comprehensive strategy
A multifaceted strategy is needed to assure success of global tobacco control. The components of such a strategy will include (a) education and information, (b) legislative measures, (c) litigation, (d) economic measures, (e) cessation efforts, (f) crop substitution and diversification, (g) advocacy, and (h) administration and management. Also, it is essential that strong political support at a national level can be reinforced by supportive international agencies. Appropriate surveillance and evaluation mechanisms are essential to assess the effectiveness of specific interventions.
Education and information
Evidence about the addictive nature of nicotine, and other harmful effects of tobacco use, need to be widely disseminated. Consumers learn about the health effects of tobacco use in many ways. One is through published scientific and epidemiological research, which may be summarized in the media. They may also learn through educational initiatives, such as school and community programmes, through warning labels on the tobacco products, and through public information campaigns or counter-advertising. All of these have been shown to be effective to varying degrees.
School health education
Comprehensive school health programmes target multiple health risk factors, including tobacco, and combine education with public policy approaches. School-based tobacco use prevention programmes that teach skills to resist social influences to tobacco use can be successful if reinforced throughout the primary and secondary school years (USDHHS 1994). School antismoking programmes are widespread, particularly in high-income countries. However, not all programmes are effective. Success depends on adequate repetition and appropriate content. Results are optimal if they are accompanied by environmental measures such as mass media campaigns and appropriate legislative measures.
Warning labels
Warnings can have a positive impact on consumers, especially on starters and those contemplating quitting, if they are highly visible and provide specific information (USDHHS 1989). Some countries, for example Canada, have taken decisive action to set a new international standard for cigarette labelling. The Government of Canada proposed new regulations requiring tough messages and graphic full-colour images that cover 50 per cent of the front of cigarette packages. The warning labels provide detailed highly visible information about the magnitude of the health risks that smokers face and the practical steps that they could take to quit (Mahood 1999). Recent Polish evidence shows direct increases in awareness and reduction in consumption as a result of new warnings. In Poland, 3 per cent of male smokers and 4 per cent of female smokers reported quitting following the introduction of strong warnings (Zatonski et al. 1999). Similar evidence of the efficacy of warnings comes from South Africa (Aftab et al. 1999). Warnings may also be expected to have a greater impact in developing countries where there has been less education about tobacco risks.
Regulatory and legislative measures
Comprehensive regulation and legislation that prohibits advertising and promotion, smoking in public places, and underage tobacco access, coupled with limits on harmful substance, tar, and nicotine contents are discussed in the section below.
Advertising and promotion bans
Tobacco advertising and promotion activities stimulate adult consumption and increase the risk of youth initiation (USDHHS 1994). Children buy the most heavily advertised brands (USDHHS 1994) and are three times more susceptible to advertising than are adults (Pollay et al. 1996). In the light of these ubiquitous and sustained pro-tobacco use messages, counter-marketing efforts of comparable intensity are needed to alter the environmental context of tobacco use. Marlboro cigarettes are one of the most successful products in the world. Its advertising campaign is perhaps the most successful in history (Elliot 1995). Advertising associates smoking with independence, enjoyment, relaxation, health, vigour, and ‘being cool’. The ‘Marlboro man’ is an outstanding and highly successful example.
Since 1972, most high-income countries have introduced stronger restrictions across more media and on various forms of sponsorship. A recent study of 22 high-income countries based on data from 1970 and 1992 concluded that comprehensive bans on cigarette advertising and promotion can reduce smoking, but more limited partial bans have little or no effect. The study concluded that if the most comprehensive restrictions were in place, tobacco consumption would fall by more than 6 per cent in high-income countries (World Bank 1999). Another study of 100 countries compared consumption trends over time in those with relatively complete bans on advertising and promotion and those with no such bans. In the countries with nearly complete bans, the downward trend in consumption was much steeper (World Bank 1999).
There are reasons to believe that young people are more receptive to advertising than are adults (Pierce et al. 1991; McCann 1992); hence an advertising ban may affect smoking incidence rates in the younger age groups more than it affects smoking cessation rates in adults. There is also growing evidence that the tobacco industry is directing increasing shares of its advertising and promotion activity toward markets where there is judged to be growth or potential for growth, including some youth markets and specific minority groups among whom tobacco use has been uncommon until recently.
Although Internet advertising is only a recent phenomenon, there are 50 million Internet access points at present around the world and growth to 500 million is expected by the end of 2000. Hong Kong has banned placing tobacco advertisements on the Internet. In Sweden, many use the Internet to purchase cigarettes by mail order from countries where prices are low. As companies advertise and sell tobacco products on the Internet, there is a need to ban this through a global process.
The European Union’s ban on tobacco advertising and promotion in the 15-country European Union has been a successful milestone. In 1998, the European Commission adopted a directive stipulating that all direct and indirect advertising (including sponsorship) of tobacco products will be banned within the European Union, with full and final enforcement of all provisions by October 2006. The key points of the directive, which is now under implementation, are as follows.

All member states of the European union must introduce national legislation by 30 July 2001.

All advertisements in the print media must cease within one further year.

Sponsorship (with the exception of events or activities organized at a global level) must cease with two further years.

Tobacco sponsorship of world events, such as Formula One motor racing, may continue for a further 3 years, but must end by October 2006.

Product information is allowed at points of sale.

Tobacco trade publications may carry tobacco advertising.

Third-country publications, not intended specifically for the European Union market, are not affected by the ban.
Clean indoor air laws
Clean indoor air laws in public places are important because they protect non-smokers from exposure to tobacco smoke, reduce smoker’s consumption of cigarettes, and induce some smokers to quit (Brownson et al. 1997; Chapman et al. 1999). Many countries are implementing restrictions on smoking in public places such as public buildings, restaurants, schools, day-care centres, and transport facilities. Clean indoor air policies alter tobacco use behaviour in young adults. Chaloupka and Wechsler (1997) found that relatively strong restrictions on smoking in public places discourage college students from smoking. Evans et al. (1999) found that workplace smoking bans reduce smoking prevalence by 4 to 6 per cent and average daily consumption among smokers by 10 per cent. Furthermore, they found that workplace smoking bans have the largest impact on staff who work longer weeks and the smallest impact on part-time workers.
Youth access laws
Youth access laws limit the supply of tobacco products to youths who are too young to comprehend the risks of consuming tobacco products. Youth access laws are designed to limit the availability of tobacco to minors from commercial sources (stores, pharmacies, vending machines, samples from distributors). The rationale for governments enacting youth access restrictions rests primarily on the fact that minors should be protected from the inherent dangers of tobacco as they do not know how to access or accurately appreciate the risks of becoming addicted to nicotine (USDHHS 1994). Jurisdiction attempts to prohibit the sale of cigarettes to minors by establishing minimum age-at-sale laws, banning self-service displays, limiting vending machines to adult-only locations or banning them completely, banning the sale of loose cigarettes, and outlawing the distribution of free samples to minors. Additionally, some jurisdictions require retail vendors to be licensed to sell tobacco products, and some laws include revocation of the license if retailers repeatedly violate minimum age-at-sale laws. In general, youth restrictions are difficult to enforce, because youths often obtain cigarettes from their older peers and sometimes from their parents. There have been several unsuccessful attempts to impose restrictions on the sale of cigarettes to teenagers in many developed countries. In many developing countries where tobacco consumption is rising, the infrastructure and resources needed to implement and enforce such restrictions are not available.
The literature provides mixed evidence on the effectiveness of youth access laws in reducing youth smoking prevalence. Retailer compliance with laws prohibiting sales to minors can be increased through active enforcement (DiFranza and Brown 1992; Cummings et al. 1998; Forster and Wolfson 1998), educational interventions (Altman et al. 1991; Feighery et al. 1991; Gemson et al. 1998), and community involvement (Forster et al. 1998). Forster and Wolfson (1998) summarize workable policies to restrict youth access to tobacco. Strong youth access intervention programmes should enforce one or all of the following means of restricting supply:

complete restrictions on distribution, such as bans on free samples and coupons

regulation of the means of sale through bans or locks on vending machines, placement of tobacco products behind service counters to limit self-service, and prohibitions on the single/loose cigarettes;

regulation of the seller through tobacco products licensing requirements, which includes possible revocation and the passage of minimum age-at-sale laws whose violation results in stiff penalties and fines.
Even successful efforts to reduce sales in stores can be determined in two ways. First, young people can often locate the small percentage of stores that continue to sell to minors. Additionally, young people often can find an older (or older appearing) friend or acquaintance who will purchase tobacco for them.
Limits on harmful substances, and tar and nicotine content
WHO and the Norwegian Ministry of Health held a conference on regulating tobacco products in Oslo in February 2000 (WHO 2000c). Representatives from 20 countries, from all regions, produced the following recommendations, among others, concerning harmful substances and tar and nicotine.

Ban the use of misleading terms such as ‘light’, ‘mild’, and other words or imagery (including certain brand names), which have the aim or effect of implying a reduced health risk attributable to low tar or nicotine measurements on tobacco products and in advertising/promotional material.

Remove tar and nicotine measures derived from International Organization for Standardization methods from packages. Warning labels should emphasize the addictiveness of tobacco products.

Require tobacco manufacturers to disclose the contents, purpose, and effects of constituents in all their products at regular intervals.

Discontinue harm reduction strategies based on simple interpretation of tar and nicotine yield measurements. This means abandoning the strategy of seeking lower nominal tar yields and instead, finding approaches that genuinely reduce harm to nicotine users.

Give urgent priority to studying the implications for harm reduction of reducing levels of nicotine and other possible addictive constituents in tobacco products over time.

Develop and implement a comprehensive long-term communication programme to accompany all the above actions that stresses that there is no safe cigarette and that nicotine addiction is a major public health concern.

In order to reduce the addictiveness of tobacco products, research is urgently needed to evaluate the benefits and/or hazards of reducing nicotine and other possible addictive constituents in tobacco products over time. Particular attention should be given in research to determining whether a threshold exists for addictiveness.

Determine whether countries should forbid addition of all new additives and explicitly address the possibility of reducing the use of additives that make tobacco products more attractive and/or taste better.
These recommendations are likely to be implemented in some form over the next few decades by many countries and represent a significant new focus of tobacco control efforts.
Economic measures
Evidence from several countries shows that price increases on cigarettes are highly effective in reducing demand. Higher taxes induce some smokers to quit and prevent others from starting. They also reduce the number of ex-smokers who return to cigarettes and reduce consumption among continuing smokers. On average, a price rise of 10 per cent on a pack of cigarettes would be expected to reduce demand for cigarettes by about 4 per cent in high-income countries and by about 8 per cent in low- and middle-income countries (World Bank 1999). Children and adolescents are more responsive to price rises than older adults, and so this intervention would have a significant impact on them. Models show that tax increases that would raise the real price of cigarettes by 10 per cent worldwide could result in 40 million smokers alive in 1995 quitting smoking, and prevent a minimum of 10 million tobacco-related deaths. Currently, in high-income countries, taxes average about two-thirds or more of the retail price of a pack of cigarettes. In lower-income countries taxes amount to not more than half the retail price of a pack of cigarettes (World Bank 1999).
Several myths exist in the economics of tobacco control. First, it is often believed that smokers always bear the costs of their consumption choices. The reality is that smokers do impose certain costs on non-smokers. These costs include health damage, nuisance, and irritation from exposure to ETS. In addition, smokers may impose financial costs on others (such as bearing a portion of smokers’ excess health care costs). In high-income countries, smokers’ health care costs on average exceed those of non-smokers in any given year (Warner 2000). Second, it is often argued that tobacco control will result in permanent job losses for an economy. In actuality, tobacco control policies will lead to only a slow decline in global tobacco use so that the transition will be phased over several decades. Furthermore, money not spent on tobacco will be spent on other goods, generating alternative employment. Third, many believe that governments will lose revenues if they increase cigarette taxes, because people will buy fewer cigarettes. The reality is at complete variance with this claim. The evidence is clear: calculations show that even very substantial cigarette tax increases will still reduce consumption and increase tax revenues. This is in part because the proportionate reduction in demand does not match the proportionate size of the tax increase. In addition, some of the money saved by quitters will be spent on other goods, which are also taxed. Historically, raising tobacco taxes, has never once led to a decrease in cigarette tax revenues.
Finally, it is often claimed that cigarette taxes have a disproportionate impact on the poor. Although less wealthy individuals tend to smoke more, it does not necessarily follow that the poor pay a greater share of their income in tobacco taxes. This reasoning ignores the effect that tax increases have on the prevalence and initiation of tobacco use, and also ignores the benefits of cessation; it ignores the evidence that shows that the young and the poor are more responsive to price increases. It is also instrumental to note that the main concern of policy-makers should be the distributional impact of the entire tax and expenditure system, and not particular taxes in isolation.
Programmes that assist young and adult smokers to stop smoking can produce a quicker public health benefit. Smokers who quit before the age of 50 halve their risk of dying in the next 15 years (USDHHS 1990). In addition, the cost savings from reduced tobacco use resulting from the implementation of moderately priced and effective smoking cessation interventions would more than pay for these interventions within 3 to 4 years (Wagner et al. 1995). Nicotine replacement therapy increases the effectiveness of cessation efforts and also reduces individual withdrawal costs. Yet, nicotine replacement therapy is difficult to obtain in many countries, although evidence suggests that it could increase demand for and effectiveness of cessation efforts (Fiore et al. 1996). Under new proposals announced by the United Kingdom government in December 1998, £60 million was being made available to set up a comprehensive service within the National Health Service to help people stop smoking. Proposals included providing a week’s supply of nicotine patches free to smokers on low incomes (Anonymous 1998). Deregulation of nicotine replacement products should permit governments to improve the success of tobacco control. Such products are increasingly available in Western countries, but they are much less available in developing countries (WHO 1999a).
Crop substitution and diversification
Historically, tobacco is a highly attractive crop to the farmers, providing a higher net income yield per unit of land than most cash crops and substantially more than food crops. In the best tobacco growing areas of Zimbabwe, tobacco is approximately 6.5 times more profitable than the next best alternative crop. Farmers also find tobacco an attractive crop for more practical reasons because the global price of tobacco is relatively stable, the tobacco industry provides in-kind supports and loans to the farmers, tobacco is less perishable than many other crops, and the industry assists with delivery or collection (World Bank 1999).
There have been a number of experimental schemes to substitute other crops for tobacco. However, there is no hard evidence, except in Canada, that these schemes succeed. Crop substitution will have a place in broader diversification programmes, if it aids the poorest tobacco farmers in their transition to other livelihoods (World Bank 1999).
Advocacy for policy change is the cornerstone of WHO’s current approach to tobacco control. The direction that this work should take was set early. ‘Tobacco is a killer. It should not be advertised, glamorized or subsidized,’ said Dr Gro Harlem Brundtland the day she took over as Director General of the WHO in May 1998, and she backed those words with immediate action. The Tobacco Free Initiative (TFI) was launched as a cabinet project with the principal remit to negotiate the Framework Convention on Tobacco Control (FCTC)—the first set of legally binding rules devoted entirely to a public health issue (WHO 2000d).
‘Tobacco kills—don’t be duped’ is the leitmotif not just of a 15-country media and non-governmental organization (NGO) advocacy programme, but it also emphasizes TFI’s basic premise, which is to expose tobacco industry tactics in subverting science, economics, and public policy. Each of the 15 countries, which include China, Brazil, Norway, Pakistan, Germany, India, and Iran, will bring special insights to the FCTC process. The ‘Don’t Be Duped’ campaign will strengthen the ability of broadcast and print journalists, NGOs, and health communicators at country, regional, and local levels to sift fact from fiction about tobacco use, sales, and promotion. The campaign, faithfully mirroring progress on FCTC, will make the case for health, enhance population health literacy, and, most importantly, influence public policy so that robust tobacco control measures and strict regulation of the tobacco industry become a reality (WHO 2000b).
As the ‘Don’t Be Duped’ campaign ploughs the global media and communications landscape to reflect TFI’s basic remit, an international coalition of NGOs—the Framework Convention Alliance—has been formed to support the development of a strong FCTC. The alliance includes individual NGOs working at the local or national level as well as existing coalitions and alliances of NGOs working at national, regional, and international level.
The task at hand is formidable. The multisectoral nature of the tobacco problem in particular and health in general has meant that the TFI must assume the role of a pathfinding advocate to place health at centre stage as a key variable in national development. ‘If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked,’ said Dr Brundtland in her opening address to the Kobe Conference on Women and Tobacco in November 1999, as the TFI began work on the FCTC.
Litigation can be an effective public health intervention in the area of tobacco control. This has been demonstrated most dramatically by recent events in the United States. In the mid- and late-1990s, there was a new wave of litigation against the tobacco industry in the United States. There were a variety of forms of litigation, including lawsuits filed by individual smokers, class action lawsuits by large groups of smokers, and lawsuits filed by victims of ETS. To date, the most successful litigation against the tobacco industry in the United States has been a series of actions brought by the Attorneys General of individual states.
The lawsuits brought by the Attorneys General focused on the conduct of the tobacco industry, not merely the product per se. Among other things, these lawsuits sought to recover the enormous sums of money that the states spent in health care costs for persons with smoking-related disease. These lawsuits alleged that the tobacco industry had misrepresented and concealed the health risks and addictiveness of smoking, manipulated the form and/or amount of nicotine in cigarettes to ensure their addictive potential, conspired to suppress health research, and targeted youth in their advertising and marketing campaigns. Thus, the legal bases for these lawsuits generally focused on consumer protection and antitrust statutes (JAMA 1995).
The Attorneys General lawsuits were all successfully resolved by settlement with the tobacco industry in 1997 and 1998. The settlement agreements are resulting in the payment of billions of dollars to the states. While the ultimate disposition of this money is not entirely resolved, and in some cases is the subject of fierce political battles, some of the funds are being dedicated to tobacco control efforts, infusing the tobacco control community with unprecedented levels of funding. In addition, beyond the monetary terms, the settlements provided for a variety of injunctive relief, including the prohibition of marketing to children, the banning of certain types of advertising and promotion (i.e. billboards and movie placements), and the dissolution of two of the tobacco industry’s long-time trade groups, the Tobacco Institute and the Council for Tobacco Research.
The Attorneys General litigation and settlements also resulted in the release of millions of pages of previously secret documents from the files of the tobacco industry. These documents paint a damning picture of the tobacco industry’s conduct for decades, and contain a wealth of information that can help guide public health activities for years to come.
The litigation was successful in the United States in large part because new successful alliances forged between attorneys and the public health community. The American Medical Association, in an unusual step, recommended in 1995 that ‘all avenues of individual and collective redress should be pursued through the legal system’ (JAMA 1995). Prominent public health professionals provided invaluable assistance in the litigation by serving as expert witnesses.
Litigation against the tobacco industry is now being pursued in a number of countries, including Canada, France, India, Israel, Ireland, Germany, Australia, Poland, South Korea, and the Marshall Islands. In many countries, this type of litigation is unusual, and it is too early to anticipate how the various actions will play out.
The risks and challenges of litigation against the tobacco industry (which fiercely opposes lawsuits with virtually unlimited resources) are very large. In the United States, for example, litigation against the tobacco industry began in 1954, and for more than 40 years (until the breakthroughs in the 1990s) the tobacco industry won every single case. Thus the prospect of litigation needs to be carefully evaluated before any decisions to proceed are undertaken. However, the potential rewards in terms of public health objectives can be enormous. In some jurisdictions, where there are promising theories of liability and sufficient resources, litigation may be one way to achieve tobacco control objectives in a forum—the courts—which may not be subject to the same political influences as legislative bodies.
Administration and management
An effective global tobacco control programme requires an efficient management structure to facilitate co-ordination of programme components at the country, regional, and global levels. Experience from other successful public health programmes, such as smallpox and poliomyelitis, has demonstrated the importance of having all of the programme components co-ordinated and working together. Because a comprehensive programme involves multiple partners, programme management and co-ordination is a challenging task. Furthermore, co-ordinating efforts require adequate resources and communication systems. Administration and management activities include (a) recruiting and developing qualified, technical, programme, and administrative staff, (b) co-ordinating implementation across programme areas and assessing programme performance, (c) creating an effective communication system, and (d) developing a sound fiscal management system.
Surveillance and evaluation
Surveillance of tobacco use can guide policy decisions, research initiatives, and the development and evaluation of intervention programmes (Giovino 2000). Tobacco surveillance is not a priority in most countries, with motivations ranging from lack of resources to underestimation of its need and importance. It has been observed that events in one country can quickly have consequences in others, and no single country or region can undertake establishing a surveillance system in isolation. As a function, surveillance requires collaboration on systems and standards for information that will transform data into ‘intelligence’, which is actionable on infrastructure for data collection and analysis at country, regional, and global levels. An ideal surveillance system would monitor variables contained in the traditional epidemiological model of agent, host, vector, environment, and incidental host (Giovino 2000; Orleans and Slade 1993).
Surveillance of agent factors (i.e. various tobacco products) may include monitoring the toxic constituents, pH, and additives. Most surveillance work monitors host factors (i.e. smoker/user or potential smoker/user) and the measures may include: patterns of initiation, susceptibility of tobacco use, indicators of dependence, quitting patterns and methods, receipt of advice to quit from physicians and dentists, mental health indicators, use of behaviours, sources of tobacco, prices paid for cigarettes, usual brand, receptivity to marketing, awareness of tobacco control programmes, and opinions about tobacco control policies. Surveillance of vector (i.e. tobacco product manufacturers) includes chronicling tobacco industry public relations, lobbying and marketing activities. Environmental surveillance (economic, cultural, political, and historical) includes national tobacco control legislation and programmatic activities, exposure to health messages; and tobacco promotions, prices and placements (Giovino 2000).
Although surveillance is a crucial part of evaluation research, specific evaluation surveys and data collection systems are needed to evaluate individual programme activities. Programme evaluations should be built upon and complement tobacco-related surveillance systems by linking programmes at national, regional, and global levels to facilitate progress towards intermediate and primary outcome objectives. Optimally, evaluation systems should be able to track the progress of each programme element related to the objectives.
Role of international agencies
World Health Organization
The TFI’s long-term mission of global tobacco control is to prevent and reduce the deaths and disease caused by tobacco use (WHO 1999b). The tentative global targets are:

lowered rate of initiation of tobacco use in children and youth

increased quitting rates among smokers

reduced number of cigarettes per capita

no increase in smoking rates among women

reduction in the number of children and adults exposed to ETS worldwide
A priority for the WHO is the development and negotiation of the FCTC. In May 1999, the 191 member states of paved the way for multilateral negotiations to begin on the FCTC and possible related protocol agreements. As the primary specialized agency addressing health matters, the WHO has the legal authority to serve as a platform for the development of binding treaties that potentially address all aspects of tobacco control, national and transnational, as long as advancing human health is the primary objective of such agreements. Major tobacco growers and exporters, as well as several countries in the developing and developed world that face the brunt of the tobacco industry’s marketing and promotion, and the five members of the United Nations Security Council, strongly supported the need for an international treaty to address the tobacco control epidemic. Moreover, the decision to proceed with FCTC negotiations represented the first time that member states of the WHO have harnessed the organization’s capacity to develop binding international conventions or agreements to protect and promote global public health. The WHO’s global strategy has the potential to advance rapidly multilateral co-operation and effective action for tobacco control worldwide.
The framework convention protocol approach has been used to address a wide range of international concerns, including environmental, arms control, and human rights issues. The term ‘framework convention’ does not have a particular technical meaning in international law. It is used to describe a variety of legal agreements which establish a general system of governance for an issue area, such as global tobacco control. Framework conventions, unlike more comprehensive forms of treaties, do not attempt to resolve all significant issues in a single document. Rather, they divide the negotiation of separate issues into separate agreements. States first adopt a framework convention, which creates an institutional forum in which states can co-operate and negotiate for the conclusion of separate implementing protocols containing detailed obligations or added institutional commitments. The framework convention/protocol approach is, in essence, a dynamic and incremental process of global law-making. This flexible approach to international law-making allows the political will of states, as signatories to international legal agreements, to be titrated gradually into legally binding commitments.
The rationale for the FCTC rests on the fact that the global and national dimensions of tobacco control are highly interdependent. The FCTC and its possible related protocols will aim to address cross-border issues as a global complement to national policy actions.
The WHO Framework Convention will provide an effective instrument for counteracting the globalization of the tobacco pandemic by serving as a platform for multilateral commitment, co-operation, and action to address the rise and spread of tobacco consumption. The globalization of the tobacco epidemic restricts the capacity of countries to control tobacco unilaterally within their sovereign borders (Bettcher and Yach 1999). All transnational tobacco control issues, including trade, smuggling, advertising and sponsorship, prices and taxes, control of toxic substances, and tobacco package design and labelling, require multilateral co-operation and effective action at the global level. It is clear that national and transnational dimensions of tobacco control must be addressed in tandem; in the absence of effective international co-operation even the most comprehensive national control programmes can be unravelled (Bettcher et al. 2000).
The Framework Convention could include provisions to encourage countries to move towards comprehensive tobacco control strategies, for instance to co-operate in research, programme, and policy development, to share information, technology, and knowledge, and to meet periodically to strengthen legal commitments to global tobacco control. In addition to promoting comprehensive national tobacco control programmes, the FCTC and its related protocols can serve as a multilateral institutional forum to address aspects of tobacco control that transcend national boundaries, including advertising and sponsorship, smuggling, and the treatment of tobacco dependence. Furthermore, the FCTC Working Group (an intergovernmental technical body established to elaborate the scientific foundation for the FCTC and possible related protocols) agreed at its first meeting in October 1999 that the FCTC should focus primarily on demand reduction strategies (WHO 2000d).
Many of the tobacco control interventions to be addressed in the FCTC and related protocols, for instance taxation on tobacco products, prevention of smuggling, bans on smoking in public places, community education, and agricultural substitution initiatives, require an international multisectoral response for effective implementation. At the global level, the establishment by the Secretary General of the United Nations in 1999 of an Ad Hoc Interagency Task Force on Tobacco Control under WHO’s leadership has provided a global mechanism for strengthening collaboration between different disciplines across the United Nations system. This new co-ordinating body, endorsed by a formal resolution of the Economic and Social Council of the United Nations, represents a useful mechanism for providing multisectoral technical input to the Framework Convention process.
The negotiation of the FCTC ushers in a unique new chapter in global public health that combines an overwhelming scientific evidence base with an evolving global social movement. This work will link science and politics at the global level as a vehicle for addressing a totally preventable man-made epidemic. WHO’s leadership in this quest will inevitably break new ground on the path towards a more sustainable form of globalization in the twenty-first century.
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2 comments on “10.1 Tobacco

  1. Doing the Charleston Chew…

    Anyone who visits Charleston, South Carolina seems to fall madly in love with the city’s southern charm –and most importantly — the food. It’s no wonder the city was recently named the top U.S. travel destination, by readers of Conde Nast Travel……

  2. […] 10.1 Tobacco | Free Medical Textbook […]

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