• public policy
• tobacco industry
• prevention

2020 marks three important anniversaries for tobacco control.

On May 27, 1950, JAMA published a paper by Ernst Wynder and Evarts Graham entitled “Tobacco smoking as a possible etiologic factor in bronchiogenic carcinoma – a Study of Six Hundred and Eighty-Four Proved Cases”.1

On September 30, 1950, the British Medical Journal published a paper by Richard Doll and Austin Bradford Hill entitled “Smoking and carcinoma of the lung”.2

On May 19, 1970 the World Health Assembly passed a resolution recognising the magnitude and preventability of the problem.3

While the earlier work of Muller and others should not be discounted,4 1950 marks seventy years since incontrovertible evidence that smoking kills, and fifty years since WHO’s first strong call for action.

A recent WHO report on tobacco trends shows that the glass is half full. “For the first time…the number of people using tobacco in the world is declining, despite population growth”.5 There has been much further progress by way of action to reduce smoking including legislation, taxation, public education, smoke-free measures and cessation support. Many developed countries are seeing encouraging trends for both smoking and its consequences.6 7 In Australia, with a population of only 25 million, if present trends continue, nearly 2 million tobacco deaths will be averted from lung cancer alone between 2016 and 2100.8 WHO continues to provide strong leadership, and the WHO Framework Convention on Tobacco Control (FCTC)9 has been ratified by 181 countries, its Guidelines confirming the “fundamental and irreconcilable conflict between the tobacco industry’s interests and public health policy interests”. Following innumerable exposés demonstrating that tobacco companies are lethal, deceitful and corrupt, the industry’s reputation has sunk to such a level that the companies are concerned about their capacity to attract good staff.10 Our progress thus far has prevented tens of millions of deaths, with likely further health benefits even well beyond tobacco.11

But the glass is also half empty. Seventy years after Wynder and Graham and Doll and Hill, and after massive further evidence on the multitude of harms attributable to both active and passive smoking, smoking still causes some 8 million deaths a year.12 Even in countries that have led the way, action is partial and inadequate, and complacency is a challenge. Thanks to the advent of social media, tobacco control advocates are increasingly attacked and abused.13 The US is still not a Party to the FCTC. The tobacco industry flourishes, using every possible approach to oppose, delay and disrupt anything that might be effective in reducing smoking, and to develop new markets, including in LMICs.

A decade ago the industry seemed to be on the retreat, but the companies have strategized and re-grouped, and are now mounting their most aggressive global and national campaigns yet to stay in profitable business. They spend billions on direct and indirect marketing, lobbying, public relations, litigation, front groups and other funded agencies, and extensive use of social media, including blatant promotion to young people.14 The advent of novel tobacco products emboldens the companies to paint themselves as acting for the public good and even as purveyors of sound science and health advice. They offer stunningly hypocritical siren songs of concern and collaboration,15 reminiscent of those from bygone decades.16 Meantime, they continue to sell and promote their traditional products, make them more attractive and appealing to children and young people,17 18 and oppose and undermine evidence-based tobacco control measures.19

There is growing evidence on the harms of their novel products20 and their role in ensuring that declines in smoking are offset by increases in use of new, addictive products. But the most disturbing consequence of the focus on e-cigarettes and the rest is that governments and health organisations around the world have been distracted from focusing on the evidence-based action that is needed to reduce smoking and its harms.

Seventy years after those historic early papers, and fifty years on from a global determination to act, we should celebrate the early authors and recognise the successes – but also despair that this entirely preventable holocaust is still with us.

We now know more than ever about the comprehensive approaches that are needed to reduce smoking.21 These should be and remain our primary focus.

There is increasing interest in proposals that entail a possible endpoint such as phasing out of commercial tobacco products.22 While this may seem an impossible objective, especially outside those countries that have traditionally led the way, so once did bans on tobacco promotion, smoke-free environments, plain packaging and divestment by major investors.

The history of tobacco control shows that progress has been incremental rather than dramatic. On that basis business as usual will still leave us with 8 million deaths a year or more through to the end of the century.

So we need a continuation of pressure for comprehensive, adequately funded, evidence-based approaches. But if there is to be a change from business as usual we need to develop new big targets, and to focus even more on the vectors, and those who are willing to support and work with them.

The Impact Assessment of the WHO FCTC23 concluded that the role and activities of the global tobacco industry remain by far the most important single obstacle to implementation of measures that will reduce smoking.

In a recent commentary on the gambling industry, the editor of the Lancet, Richard Horton, wrote of “the utter evil of an industry that does indeed prey on those facing social peril and financial precarity”.24 Perhaps we have become so inured to the activities of tobacco companies that we forget to draw constant and public attention to the sheer evil of an industry that knowingly causes millions of deaths each year, and to hold directly accountable the directors and senior executives who drive their companies’ policies.

As long ago as 1967 Senator Robert Kennedy said, “cigarettes would have been banned years ago were it not for the tremendous economic power of their producers”25

In 1880 “a young Virginia inventor”, James Bonsack, submitted his new design for a cigarette making machine to the U.S. Patent Office – the starting point for the modern tobacco epidemic.4 Is it too much to hope that by 2030, the 150th anniversary of this invention, there will be measures in place to ensure the end of the uniquely lethal industry it created?