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Starting with epidemiology
The causal relationship between tobacco use and death and disease has been demonstrated in countless epidemiological studies since the pioneering work of Doll 50 years ago. Initial studies in the UK and the USA have been followed in recent years by research in China, India, South Africa, and many other countries. All reinforce and strengthen the arguments for urgent action if the public health impact of tobacco is to be reduced and ultimately stopped.
It was epidemiologists, cancer specialists, and pulmonologists who first led the waves of advocacy that have taken tobacco from being regarded as a desirable social behaviour to being seen for what it is—the most preventable cause of death in the world. Globally, 4 million people die annually from tobacco, a figure that will increase to 10 million annually within 25 years. By that time 70% of deaths will be reported from developing countries.1
As the years pass the death toll rises and the relationships between tobacco and health outcomes grow. The relationship between passive smoking and many causes of ill health in children as well as lung cancer in adults is regarded as causal2; the long neglected relationship between major assaults on tuberculosis of the lung3 and tobacco is being acknowledged and programmes to address both together are being planned; and the complex relationship between tobacco use and several forms of mental disorder are receiving attention.
The public health evidence is well beyond dispute, even by most tobacco companies. But, while the impact of tobacco is well understood, the death toll will rise for decades. The prevalence of smoking in many countries continues to grow, especially among the young and in women. The current smoking rates in 13–15 year old subjects in many countries suggest that, unless vigorous action is taken, the epidemic will expand throughout countries that are slowly bringing infectious diseases under control.4
Adding the economic dimension
Avoidable deaths and disease should be sufficient reason for governments to act. However, powerful, well constructed myths developed and disseminated by tobacco companies over decades about the economics of tobacco remain pervasive and dominate the minds of finance ministers and development agencies in many countries. The very simple notions that maintain that reduced demand for tobacco will rapidly cause job losses, unemployment among tobacco growers, and revenue losses to government have been repeated over and over again until they are believed by many to constitute conventional wisdom. But these arguments were carefully constructed and elaborated by economists and media consultants for tobacco companies while they knew full well that the truth was quite different. As the recent publications by the World Bank emphasise,5 6 tobacco harms economies; increased excise taxes yield increased revenue for governments as they reduce consumption, especially among the poor and the young; total bans on tobacco marketing of all types reduce consumption as do a combination of other measures such as better access to cessation programmes, smoke-free places, strong counter advertising, and large bold warnings.
As consumption drops, ex-smokers remain active in the economy and switch their patterns of expenditure to other goods and services which, on aggregate, usually increase overall economic activity and growth. This will lead to more jobs in the long run or, at worst, no change in the overall labour position. There are, of course, a few countries which will suffer some form of transitional impact—Zimbabwe and Malawi being two notable examples. For them a long term strategy, supported by international development agencies, is needed to facilitate the transition out of their current unhealthy economic dependency on tobacco.
It is vital, though, to stress the long term nature of likely adjustments. With 1.2 billion smokers in the world, even if global actions are very successful, there will (unfortunately) still be many hundreds of millions of smokers in the world by 2030. They will continue to keep demand for leaf tobacco relatively high.
So epidemiologists are now joined by economists in advocating tobacco control. That message extends the reach of the original public health message into the real corridors of power and decision making, but the combined health and economic arguments have still not been sufficient to move all governments to act decisively.
Exposing the truth about industry behaviour
Malaria experts cannot make progress without a thorough understanding about the function, behaviour, and weaknesses of their primary vector, the mosquito. For tobacco control experts the vectors are tobacco companies and, as we have gained knowledge about the behaviour and historical actions of the tobacco companies, new options for tobacco control have emerged. New insights into why tobacco control policies in the past have failed are available.
The source of this knowledge comes from the tobacco companies' own documents. An outcome of the USA litigation of the late 1990s has resulted in open public access to millions of pages of previously secret documents.7 They have not only been used in USA litigation but have also formed the basis for inquiries into tobacco company behaviour by the UK House of Commons, governments of Norway and Israel, as well as the World Health Organization.8
Taken together they document a pattern of deception that has been deeply pervasive throughout many aspects of science and public health. These actions range from cigarette design to facilitate addiction, to well designed programmes aimed at marketing to women and youth, to denial of the impact of passive smoking on health.9 10
Of the many adverse and secret influences on tobacco control, the impact of tobacco companies on the policy processes of governments and WHO must rank as their biggest success and public health's biggest loss. Decades of work have meant that tobacco control remains severely underfunded by governments, and implementation of effective policies by international agencies remains the topic of dispute rather than common sense.
However, the changes are coming and increasing public outrage about the extent of “duping” that has occurred now joins the solid health and economic arguments as the driving force for better health and truth in public policy.
Emerging global partnerships for action
As momentum for change increases at government level, major international players are speaking out more forcefully then before about the need for action. Within the United Nations family WHO now chairs a 15-agency United Nations Ad Hoc Inter-Agency Task Force on Tobacco Control that includes FAO, UNICEF, the World Bank, IMF and WTO. They have developed a coherent approach to tobacco control that puts demand reduction at the front, but also acknowledges the need for analytical work on supply measures.11
A wide range of non-governmental agencies (NGOs) has coalesced around the need for global action. They are drawn from more traditional health professional groups as well as from environmental, women's, youth, religious, and human rights constituencies. As their watchfulness over the action of tobacco companies in developing countries becomes truly global and their voice becomes louder and stronger, it is likely that we will witness the implementation of actions which were previously disregarded by governments. The experience gained by NGOs in mobilising governments to stop landmine production could be invaluable to effective global tobacco control.
The new “tobacco industry”
While the policy environment shifts, the strategies of tobacco companies have also shifted. They now follow twin approaches. Firstly, since the success of USA litigation we are witnessing the start of increased competition between tobacco companies with respect to health and safety claims about new and emerging products. The companies with the largest research investments believe they may win with products that they believe will yield reduced harm. They do so while acknowledging that their current products cause the health problems that WHO has maintained they cause for decades.
The second approach involves the aim of tobacco companies to regain public respectability overtly and covertly. Tantalising offers of cash for programmes to reduce youth smoking, to prevent violence against women, and to improve the investment environment are being made to small communities as well as to prestigious NGOs and universities, and even governments. Many are duped and take the money despite all the evidence about the real intent of the companies. But, increasingly, even poor communities and cash strapped governments are no longer fooled. The tide of public opinion is turning.
First use by WHO of “article 19” of its constitution
Globalisation of marketing of tobacco products that subverts national laws, global strategic planning and brand development by tobacco companies that reaches rich and poor countries, and smuggling are a few core areas of tobacco control that demand global action.12 The 191 member states of WHO have long recognised the limits of national action in the face of determined, well financed, multinationals. The current and projected epidemiological and economic impact of tobacco demands a new approach that harnesses the political and scientific capabilities of governments. The Framework Convention on Tobacco Control (FCTC) will do that. It represents the first time that WHO is using article 19 of its constitution—the right to develop legally binding treaties and conventions to address a public health threat.
Since Dr Brundtland took office in mid 1998, progress has been rapid. Working groups completed a review of technical issues to be considered in the FCTC and the first Intergovernmental Negotiating Body met in October 2000.13 They elected Ambassador C L Nunes Amorim from Brazil as Chair for the process and completed a first reading of the substantive parts of possible text. At this early stage, strong support for a total ban on advertising, sponsorship and marketing, effective national and international means of stopping smuggling, as well as several other major components of effective tobacco control were expressed by countries from all levels of development and from all regions.
These views were in contrast to those expressed during WHO's public hearings by tobacco companies.14 Representatives from most major companies offered to work with WHO and governments to implement measures that they—and now public health experts—know have extremely limited impact on tobacco use, such as better youth access laws and school education programmes. They were either opposed to or were silent on support for measures mentioned earlier that make a difference!
The next negotiating session will be held in late April 2001. There is work to do before then. Thorax readers could play a major role in ensuring that the FCTC truly protects public health—and especially lung health—by ensuring that their government delegates, health professional bodies, and NGOs are made aware of the daily toll of suffering that you all face in the wards and hospitals around the world. They need to keep this reality in mind during the FCTC negotiating process. Your voice at this crucial time could lead to a convention that is truly in the service of global health.