The need for action to stop tobacco production and consumption is patent. At present, about 4 million people a year die of tobacco-related diseases (1). WHO epidemiologists predict that unless there is a dramatic change in present trends tobacco will be killing 8.4 million people a year by the late 2020s (2). This month the Bulletin joins the BMJ and JAMA in a global theme issue to take a look at some of the factors involved.
About 1.2 billion of the people in the world who are over 15 years of age smoke. In countries where the number of young smokers is not high already,it is rising. Warren et al.(pp.868876) discuss the data on this now becoming available through the Global Youth Tobacco Survey. In many places tobacco consumption continues to rise despite the fact that ways to reduce it exist and are known to work. These measures include government regulations on marketing and access, price increases, counter-advertising, and treatment for dependence. They have proved to be effective, as Corrao et al. point out (pp.884890), failing only where they have not been wholeheartedly adopted. Now, however, they riskbeing thwarted by the new dangers that globalization brings:unopposed marketing through satellite television and Internet, and unprecedented opportunities for smuggling. Threats of this kind cannot be dealt with by countries acting on their own, and that is why governments and organizations have begun workon drafting the Framework Convention on Tobacco Control, as Taylor & Bettcher explain (pp.920929). WHO will convene the first full Intergovernmental Negotiating Committee for the convention in mid-October of this year.
Much has been done nationally as well. The Masters Settlement Agreement reached in 1998 in the USA determined that the tobacco industry should pay out $264 billion over a period of 25 years to 46 of the United States to compensate for tobacco-elated health costs (3). This and other litigation has brought to light vast quantities of secret tobacco industry documents. As Judith Mackay (pp.911912) and Ong & Glantz (pp.938939) observe, they show how the industry had known for decades that tobacco causes death and is addictive, and had been very concerned about it. Such is the power of corporate thinking, however, that the industry found a solution:properly managed, the lethality of tobacco could be compensated for by its addictiveness, which would guarantee the fidelity of survivors and new recruits, so all would be well (for the industry).
Saloojee & Dagli (pp.902910) explain how this sinister strategy of drawing new customers into addiction while old ones die of it is concealed by an array of attractive images which associate smoking with its opposites freedom, fresh air, independence, physical strength and beauty, happiness and respectability. Ernster et al. (pp.891901) provide fascinating information on how a previously neglected clientele, women, are drawn into the belief that smoking is glamorous.
Spokespeople for the industry often argue that its aim is not to recruit new smokers but to offer existing ones a better product and win a larger piece of the market for their shareholders. These objectives fall squarely within the morality of good business, but only help to explain the ferocity of the competition between major multinational tobacco companies to win new clients in developing countries. The Global Analysis Project Team (pp.913919) reviews the progress of these efforts in Thailand and Zimbabwe, and the responses of stake-holders in the three main areas of tobacco control: production, regulation of consumption, and health promotion. In this context Luk Joossens (pp.930937) spells out the need for international harmonization of taxes on tobacco products, a worldwide ban on tobacco advertising, and other measures for bringing the industry under control.
Despite the wealth and inventiveness of the industry, the tide is beginning to turn against it, and the value of tobacco has tumbled on stockexchanges worldwide. Between November 1998 and April 2000, tobacco stocks on the Standard and Poors 500 Index lost 60% of their value. In more and more countries, public opinion and policy are turning against smoking. Chemical aids to overcoming nicotine addiction are being aggressively marketed by pharmaceutical companies. New products, making untested claims of being less harmful, are appearing on the market. Feeling seriously threatened, the industry is seriously fighting back, and it is therefore of the utmost importance to press home the current advantage. This means joining wholeheart-edly in national and international anti-tobacco campaigns, fully supporting the 11th World Conference on Tobacco or Health in Chicago, USA, 611 August (information at www.who.int/toh/fctc) and, above all, supporting the Framework Convention on Tobacco Control. It is for the public health community to lead the way in solving this entirely unacceptable public health problem.§
1. The world health report 1999 Making a difference. Geneva, World Health Organization, 1999: 65.
2. Murray CJL, Lopez AD. Assessing the burden of disease that can be attributed to specific risk factors. In: Investing in health research and development. Report of the Ad Hoc Committee on Health Research Relating to Future Intervention Options. Geneva, World Health Organization, 1996 (unpublished document TDR/Gen/96.1 available from Tobacco Free Initiative, WHO, 1211 Geneva 27, Switzerland).
3. Dagen H, White J. Governments, citizens and injurious industries. New York University Law Review, New York, May 2000.
1 Vice President, The Robert Wood Johnson Foundation, Princeton, NJ, USA.
2 Executive Director, Noncommunicable Diseases and Mental Health; and Programme Manager, Tobacco Free Initiative, World Health Organization, 1211 Geneva 27, Switzerland. Correspondence should be addressed to this author.
Ref. No. 00-0835