Tobacco control at twenty: reflecting on the past, considering the present and developing the new conversations for the future
- 1Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, San Francisco, California, USA
- 2School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
- Correspondence to Dr Ruth E Malone, Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, San Francisco, California 94118, USA;
- Tobacco industry
- qualitative study
- marginalised populations
- industry public relations/media
- industry documents
- harm reduction
- taxation and price
- advertising and promotion
- public policy
This issue marks a milestone: 2 decades of publication for Tobacco Control, which began publishing in 1992 as the only journal focused primarily on the topic. Our 20th anniversary issue invites the tobacco control community to reflect, analyse achievements and challenges, and further articulate our collective global vision of a tobacco-free future that would spare the suffering and early death of millions. Major achievements of the last 20 years make new conversations possible. Major remaining (and emerging) challenges make these new conversations essential.
Had a veteran tobacco control policy researcher or advocate hibernated in 1992 and awakened today—let's call him Rip Van Tobacco—he would not believe the world of tobacco control his eyes beheld in 2012. Rip would quickly learn that the workplaces of 46 entire countries were 100% smoke-free, including all restaurants and bars, led in 2004 by cigarette- and pub-loving Ireland.1 Engaging in some simple web research—using technologies virtually unheard of in 1992—he would find that literally millions of previously secret documents from the tobacco industry are available for anyone to read at the touch of their fingertips. Indeed, he would learn of an entirely new field of tobacco control research known as tobacco industry documents research, documenting in detail tobacco companies' efforts to thwart regulation and deceive the public about the disease effects of their products: research that formed the basis for public and private lawsuits against the industry in the USA and elsewhere.
Our mythical tobacco control professional would be shocked to learn that there was a global tobacco control treaty—the Framework Convention on Tobacco Control (FCTC)—that had been ratified by 174 countries and was actively moving low- and middle-income countries—not just high-income nations—to create smoke-free public places, restrict tobacco advertising and promotion, and raise tobacco product taxes to unheard-of levels.i He would marvel at the fact that tobacco was the subject of the world's first-ever global health treaty and that it represented the first time that WHO had utilised its long-standing authority to mount international health treaties. He would be incredulous that tobacco control had become a global movement, looked to and emulated by activists in other health and social arenas. He would be stunned to hear of the Framework Convention Alliance (FCA), a group of over 350 civil society organisations from 100+ countries, actively involved in working towards effective FCTC implementation and monitoring, and communicating daily through a worldwide instant-communication network.
Speaking of taxes, Rip would be astonished that the price of cigarettes exceeded $10 per pack in some countries. Most amazing of all, he would be impressed to see policymakers explicitly discussing the need to protect tobacco control programmes and policies from the influence of the tobacco industry rather than focusing solely on teaching individuals that smoking was bad for their health and trying to deter children from taking it up.
Despite these extraordinary developments, Rip would not be entirely delighted with progress in tobacco control, particularly when he learnt that cigarette consumption in some countries was still increasing, and when he saw that multinational tobacco companies had become even more powerful and aggressive in targeting people in low- and middle-income countries, especially youth, women, the poor, the undereducated and other marginalised groups. Indeed, he would feel incredibly frustrated, and truly shocked, that adult smoking prevalence in the USA had declined just 5% since 1992, from about 24.5% to 19.3% in 2010. How could that be in a land in which 30 states now prohibited smoking in all workplaces, restaurants, and bars and average cigarette price stood at nearly $6.00?! Prevalence had declined more than twice that much in the 20 years prior to Rip's prolonged nap! However, he would note with satisfaction that in states like California, which had instituted strong tobacco control programmes that worked to change social understandings about smoking and about the tobacco industry itself, prevalence had declined far below the national average.
Rubbing his eyes disbelievingly, he would be disturbed to hear about new industry strategies to promote tobacco use through social media that did not even exist when he nodded off, as well as through retailing, sponsorship and ‘corporate social responsibility’ initiatives. The irony of tobacco companies building clinics in poor countries in order to curry favour with local politicians would distress him, particularly when he learnt how high the smoking rates among health professionals remained in these countries. He might be shocked to learn that tobacco company CEOs had finally acknowledged that their product was hazardous to health, that they now concurred that cigarettes caused lung cancer and heart disease, and that there was ‘no safe cigarette.’ And yet—this Rip would find mind-boggling—despite these admissions, they continued to aggressively promote their use!
Finally, Rip would certainly be surprised and delighted to find that since he went to sleep, an international, highly-respected journal devoted to tobacco control research had been established and published for 20 years, achieving an outstanding level of prominence and reach for a specialty journal.
This issue offers a partial snapshot of our imaginary Rip's awakening moment in the tobacco control movement, a pivotal moment in multiple ways. The snapshot is partial because we had limited space to try to cover an enormous and continually burgeoning field that includes a broad range of disciplinary sciences as well as the strategic dialogues of the advocacy and funding communities. Many of the papers featured in this issue have been authored by leaders in the field. In some cases, busy people were unable to commit to preparing or revising a manuscript on a selected topic within our deadlines, and so some gaps remain. In some cases, reviews on selected topics had just been published or were immediately pending publication elsewhere. A topic's absence, therefore, does not indicate lack of editorial interest. The moment is pivotal because “we no longer lack knowledge of tobacco's harmfulness, of ways to reduce and prevent its use, and of how the industry works to thwart tobacco control efforts. What we lack is sufficient political will in many countries across the globe to take the structural steps to bring the tobacco epidemic to an end.”
The three editorials that lead the issue offer perspectives on the state of the field as we head into the journal's third decade. Following this one, which provides an overview of the issue's contents, Mackay and colleagues (page 77) touch on the enormous progress made and highlight the major challenge that confronts us today: the industry vector in its many forms. Next, Editor Emeritus Simon Chapman (page 80) exercises his trenchant pen (or keyboard) to skewer the tobacco industry's response to the path breaking Australian plain-packaging initiative, the latest policy that magnificently reinforces Australia's current title as a global tobacco control leader.
David Simpson's pungent news analysis (page 82) has been a beloved feature of the journal since its inception. For this special issue, he offers his commentary on a non-randomly selected set of top tobacco control news items covered in the News Analysis column over the past 20 years, as well as some of the top stories today.
How did this industrially produced epidemic of tobacco disease come to be? Examining the shameful past with a historian's eye, Proctor (page 87) traces the historical pathways by which the cigarette–lung cancer link was discovered, then denied and obscured as millions died. Aguinaga Bialous and Peeters (page 92) bring us up to speed on the tobacco industry, a far different and perhaps even more dangerous animal in its structural configuration than it was 20 years ago. Moving forward in time to examine the tobacco epidemic today, Thun and colleagues (page 96) revisit the landmark ‘stages of the tobacco epidemic’ model that was proposed in 19942 to appraise how accurately it predicted what actually occurred during the ensuing time period across the globe, and update its projections to 2025. Warner and Tam (page 103) recap some of the major achievements in tobacco control research over the last 2 decades that have created the scientific basis for effective tobacco control policies. Using US data, Zhu and colleagues' paper (page 110) demonstrates that despite the burgeoning development of a range of cessation interventions over the past 20 years, there is no consistent trend of increase in the population cessation rate, arguing that increasing the rate of quit attempts may be the key to improving smokers' odds of successful smoking cessation. The evidence presented by Zhu et al shows us that the complex issue of improving cessation success is very much unfinished business. Gilmore (page 119) provides an analysis of the tobacco industry's strategies to sustain profits through its use of pricing power in different countries and regions, suggesting more effective policy approaches.
A set of review papers cover key topics in the field, including Durkin and colleagues on mass media campaigns for smoking cessation (page 127); Freeman on new media and its implications for tobacco control (page 139); Henriksen on marketing and promotion (page 147); Hyland et al on smokefree air policies (page 154); Malone and coauthors on tobacco industry denormalisation as a tobacco control intervention (page 162); Amos and colleagues on sex and gender in tobacco control (page 236); Chaloupka and colleagues on the economics of tobacco control (page 172); O'Connor on non-cigarette tobacco products (page 181); and Lecours et al on the environmental health impacts of tobacco farming (page 191) followed by Chapman and Derrick's brief bibliographic analysis of papers and authors published in the journal since 1998 (page 198).
The Lighter Side has long been a favourite feature of Tobacco Control readers, and for this special issue, Stan Shatenstein and Norbert Hirschorn offer a selected set of ‘the best of’ this feature.
Turning next to a set of papers that take up strategic directions and emerging issues in the field, Dresler and colleagues (page 208) show how global human rights instruments have relevance for tobacco control. Lieberman draws on his experiences participating as part of the FCA at the FCTC Conferences of the Parties (COP) to consider where we stand post-COP4 (page 215). McNeill and colleagues take up the challenge of proposing strategies for tobacco product regulation, urging abandonment of the notion of ‘safe’ or ‘safer’ cigarettes (page 221). Daynard and LeGresley (page 227) follow with a brief discussion of the role of product liability litigation and how it can play a supporting role in achieving justice for those harmed by tobacco across the globe.
The tobacco industry today makes much of how virtually any serious tobacco control effort is likely to increase smuggling and illicit trade. Joosens and Raw (page 230) examine the changing nature of these phenomena and the requirements a strong FCTC protocol on illicit trade should have. Ayo-Yusuf and Burns (page 245) take up the challenge of considering how ‘harm reduction’ with smokeless tobacco might play out in low- and middle-income countries. Aveyard and Raw's paper (page 252) considers ways to improve smoking cessation approaches at the level of individuals, while Pierce and his colleagues (page 258) consider the other side of the coin: how to prevent youth smoking. Finally, two short essays by Cohen et al (page 265) and Doherty and McNeill (page 267) consider the ‘hardening’ hypothesis, the idea that as more smokers quit, those remaining are a different, ‘hardened’ group constituting those more resistant to quitting or unable to do so.
Every movement needs its visionaries, those who lead the field forward with ideas that are at first regarded as radical, then often grudgingly considered, then gradually embraced as ideas take root in the collective imagination. A selection of pieces by some of the movement's visionary thinkers concludes the issue: First, Wipfli and Samet (page 269) argue that we must broaden the reach of the movement towards global disease control, and offer suggestions for doing this. Jeff Collin (page 274) confronts the inconsistency of tobacco control policies with development and other policies and suggests that what has been characterised as ‘tobacco exceptionalism’ is perhaps not as exceptional as it once seemed. Reddy and colleagues (page 281) offer some practical suggestions for linking tobacco control to development goals.
Leading us forward into the future are a set of forward-thinking commentaries on a topic that continues to provoke discussion and debate, and stretches assumptions about the possible: the idea of how a tobacco ‘endgame’ might be achieved. Borland (page 287) argues for a regulated market model that takes control away from tobacco companies. Daynard pushes out to the year 2032 to imagine the numerous ways an endgame might be effectively pursued, including phasing out smoked tobacco by reducing nicotine to non-addictive levels (page 289). Directly controlling the industry is the focus of Callard and Collishaw's (page 291) piece, which argues that we need to ‘disable the pump’ of the industry vector to reach an endgame for tobacco. Thomson and colleagues (page 293) suggest that an endgame must comprise both process and goal, outlining key elements that may enhance the likelihood of achieving such a goal. Virtually always having the last word in any venue, Glantz (page 296) concludes the issue with a story that shows what a difference tobacco control can make.
We also feature short commentaries on various papers solicited from advocates, scientists and practitioners throughout the world. Wherever you live and work, whatever your role in tobacco control, we welcome your comments on the content of this issue either as Rapid Responses to specific articles via our website (http://www.tobaccocontrol.bmj.com) or on our blog at the same URL. It is dialogue that moves the movement forward, even when (perhaps especially when) it is characterised by respectfully dissenting perspectives.
We are unlikely ever to see the day when everyone agrees upon exactly what should be done to address the massive toll of the epidemic, but there is virtual unanimity that the status quo cannot continue. Despite the many notable achievements since 1992, if Rip Van Tobacco takes another 20-year nap, he will awaken in 2032 expecting to see far more progress than he observes today. We must envision together a time when, our efforts bearing fruit, those who follow will ask with disbelief how we ever let the historic tobacco epidemic go on for so long.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
↵i Politically sophisticated, he likely would not have been the least bit surprised that the USA was one of the world's handful of countries that had not ratified the treaty.