Tobacco Control in the 21st Century
Authors: Thomas Houston, Nancy J. Kaufman
Journal: JAMA (2000)

THE PAST CENTURY HAS WITNESSED DRAMATIC CHANGES in all aspects of life, from the Wright brothers to the spaceshuttle; fromthe telegraphtoe-mail; fromhouse calls to robotic surgery. In matters of health, the 20th century brought increased life expectancy, dramatic shifts in basic public health practice, and shifts in morbidity and mortalityawayfromcommunicableandinfectiousdisease. Indeveloped nations, chronic illnesses, often attributable to lifestyle factors, have become major sources of ill health and premature death. And for all the health benefits realized during the 20th century, a manmade plague beset society—tobacco use. Tobacco is the leading contributor to mortality in the United States, each year claiming more than 430000 direct users and between 40000 and 67000 individuals who are exposed to environmental tobacco smoke. By comparison, in 1965, an estimated 183000 deaths were attributed to tobacco. While there were an estimated 3 million annual deaths from tobacco use worldwide at the end of the 20th century, it is predicted that this number will soar to more than 10 million by the 2020s, with the burden of tobacco-related mortality shifting from developed to developing nations. Tobacco is a global product and a global problem with multiple examples of cross-national marketing and distribution. For instance, bidis, hand-rolled in the streets of Delhi, are found in the hands and mouths of US teenagers for whom they are the latest youth smoking fad. Where national tobacco monopolies once produced products for export to the developing world, large transnational companies now manufacture cigarettes in more than 100 countries. Since 1995, these firms have established manufacturing capacity in Hungary, Tanzania, Poland, Cambodia, Mexico, Romania, Russia, Bulgaria, Ukraine, China, and many other countries, producing westernbrandsandbringingMadisonAvenue–stylemarketingcampaigns with the potential to lure new users to their products. Since 1967, tobacco control advocates, public health officials, government health workers, and public policy officials from around the world have met every 2 to 3 years to share information and ideas to stem the global scourge caused by tobacco use. This week, the 11th World Conference on Tobacco or Health, with the theme “promoting a future without tobacco,” continues these efforts. In recognition of the importance of this conference, the editors of JAMA and BMJ have devoted pages of the current issues of their journals to articles on tobacco use, consequences, and prevention. This marks the first simultaneous publication of tobacco theme issues from these journals, which have had a long history of being at the forefront of tobacco control. Efforts to combat tobacco have seen some success in the United States, but there is still a long way to go. Tobacco excise taxes in the United States are comparatively low. For example, taxes in Denmark, the United Kingdom, and India make up about 80% of the retail price. In the United States, taxes are less than 40% of the total retail price. Tobacco advertising and promotion persists, even with the recent restrictions imposed by the tobacco “settlement,” with industrysponsored music events in college bars, increased advertising in magazines with high youth readership, and public relations campaigns that provide a veneer of civic responsibility. The majority of US medical schools fail to incorporate instruction on tobacco use prevention and control in their curricula, and counseling patients about tobacco use prevention and cessation needs much more emphasis in practice. The international community may have some lessons for the United States. For example, the health ministers of the European Union have just approved changes in tobacco warning labels, requiring that they cover nearly half the face of a pack of cigarettes. Total bans on tobacco advertising and promotion are in effect in Poland and the Czech Republic, will be inplaceverysooninBritainandSouthAfrica,andwillbephased in across the other European Union nations in a few years. Because tobacco is such a profitable commodity, conflicts between trade and health interests are rampant. Recent US trade agreements with China, which are in process, could have significant adverse health effects because of newfound access to Chinese markets by the US tobacco industry. A recent commentary expressed concern about possible changes in World Bank policy on the appropriate priority level for noncommunicable disease interventions in developing nations. The author noted that the World Bank seems to be defending transnational corporate interests by “converting tobacco into an issue of individual choice rather than one of collective responsibility for public health . . . ” and goes on to state that “free trade has health consequences [that] should be faced, not shouted down.” It is time that the health consequences of international trade be considered, and health concerns put on equal footing with commerce. Curbing the use of tobacco products and protecting nonusers from the hazards of environmental tobacco smoke is a matter of politics as well as public health, and the efforts of the health community are often ignored in the process. Despite the expectation that monies from the tobacco settlement would be used for tobacco control, the public health community in a number of states has not been successful in securing