BOOKS & ELECTRONIC MEDIA
Tobacco: science, policy and public health
Tobacco smoke and involuntary smoking (IARC Monographs, Volume 83)
Yale School of Public Health, 60 College Street, PO Box 208034, New Haven, CT 06520.8034, USA (email: firstname.lastname@example.org)
Editors: Peter Boyle, Nigel Gray, Jack Henningfield, John Seffrin, Witold Zatonski
Publisher: Oxford University Press, Oxford, England; 2004
ISBN: 0-19-852687-3; 830 pages (hardback);
Publisher: International Agency for Research on Cancer, Lyon, France; 2004
ISBN: 92-832-1283-5; 1470 pages (softcover);
price Swiss francs 55.00/US$ 49.50 (Swiss francs 38.50 in developing countries)
Fifty years after Sir Richard Doll first reported results from the British doctors' study (1), two encyclopaedic books on tobacco have appeared (2, 3) which document the enormous progress that has been made in research, policy, and actions on global tobacco control. Boyle et al. have synthesized current knowledge of a field that has rapidly matured (2). And the International Agency for Research on Cancer (IARC), in its monograph on tobacco smoke and involuntary smoking, provides extremely detailed evidence from the hundreds of studies that form the basis for our concern about the harms that tobacco causes (3). These books should be compulsory reading for all involved in the control of chronic diseases and more specifically in the control of tobacco.
Both books provide a powerful evidence base for accelerated action against tobacco. Boyle et al. have involved a global "who's who" list of authors to write chapters that address the mechanisms of addiction and carcinogenesis, the composition of cigarettes and the biological impact of their constituents, the epidemiology of tobacco, key elements of the effectiveness of interventions, and country case studies of policies that have led to less smoking and fewer deaths. The IARC monograph focuses tightly on the carcinogenicity of tobacco products and does so by pulling together all major relevant studies from around the world.
What is striking when reading these massive new tomes is just how much evidence was obtained by Doll and his team over the 50-year period of his cohort study and how very little new evidence has come to light about the impact of tobacco on human health (with the exception of the impact of second-hand smoke) from the mass of other studies that have been completed over this same period. We do know more about mechanisms of action of tobacco and its products on humans, but until recently that knowledge was not of use to policy-makers. Pricing policies, marketing bans, public-place smoking bans, and high quality educational programmes have not been changed by the new understanding about the mechanisms of disease causation and of addiction.
But now, new scientific information may be of use as tobacco companies increasingly compete with pharmaceutical companies to provide nicotine to people addicted to tobacco. In 2003, just two companies, Altria and BAT, spent over US$ 500 million on new product development and are seriously gearing up to make new offerings to the public. The public health community will have to use its best knowledge to judge whether dramatically reduced exposures from new tobacco products will translate into fewer deaths and less disease well before a further 50 years of cohort studies have been completed. This will require using better biomarkers of exposure and outcomes, and simultaneously will require greater wisdom about how to communicate results to the public in such a way that "new products" do not lead to a slow down in smoking cessation rates or to continued smoking among youth. Several authors in the book by Boyle et al. correctly identify the need for urgent support to be given to cessation programmes as the principal means, together with smoke-free policies, of reducing death rates from smoking over the next two decades. The complexity of this looming debate about nicotine supply is mentioned a few times in the book without proposing a bold way forward.
A weakness of the book by Boyle et al. is that it does not explicitly address the many aspects of the globalization of tobacco marketing, trade and now control. Individual county reports are useful, but the real progress from a global perspective has arisen from the recognition that there are limits to national action in trying to control cross-border marketing, trade, investment and smuggling, and instead to attempt to promote cross-border learning about effective interventions. The WHO Framework Convention on Tobacco Control (FCTC) does, however, address these issues. It is very briefly mentioned in the book by Boyle et al. It would be have been helpful to discuss how the very process of building global consensus for the FCTC meant that nongovernmental organizations, governments and UN agencies needed to find areas of agreement where previously there had been none; and that every working group and major meeting was regarded by the 1000 or so participants as a "global university of tobacco control", which facilitated sharing of best practices in a unique manner. The FCTC process galvanized global action like never before, attracted new funding, and built coalitions that remain active 5 years after their formation.
These two books thus appear at a time when governments and tobacco control advocates are hungry for evidence of what to do to make a difference. The epidemiological studies will continue to inspire them but the following are increasingly needed if progress on paper is to lead to meaningful change:
- serious investment by all governments in tobacco control and greater use of excise tax to fund this;
- budget lines for tobacco control that are explicit and prioritize the FCTC elements priorities;
- when the above two are in place, the international donor community needs to make good on the pledges it made in the lead-up to the adoption of the FCTC. This includes the European Commission, which pledged to support tobacco control in developing countries; many foundations, some of which were active funders between 1999 and 2003 and have since reduced their support for international tobacco control; and The World Bank and regional development banks, which as a group are still not supporting tobacco control in proportion to the public health gains that investment could bring.
The country reviews in the book by Boyle et al. show that when committed people with passion and competence tackle tobacco control, much can be achieved. To sustain the progress and to expand it will, however, take a significant and needed increase in funding, and also a new infusion of leadership for tobacco control led from developing countries. IARC's new approach to tobacco control may well start addressing these issues by providing the tools needed to ensure that 50 years from now we have books released detailing the decline of an entirely preventable, costly and painful epidemic.
1. Doll R, Peto R, Boreham J, Sunderland I. Mortality in relation to smoking: 50 years' observations of male British doctors. BMJ 2004;328:1519-28.
2. Boyle P, Gray N, Henningfeld J, Seffrin J, Zatonski W, editors. Tobacco: science, policy and public health. Oxford: Oxford University Press; 2004.
3. Tobacco smoke and involuntary smoking (IARC Monographs on the Evaluation of Carcinogenic Risks to Humans). IARC Monograph 83. Lyon: International Agency for Research on Cancer; 2004.