ReviewA global approach to tobacco policy
Introduction
Policy dealing with the problem of tobacco smoking has evolved over time and has been applied to a variable degree, mostly, but not only, in developed countries. Progress against tobacco mortality has been slow and has occurred in the face of determined, well funded and persistent opposition from the international tobacco industry, whose cohesion can only be envied by the public health community.
Success can be measured in many ways, from surveys of smoking prevalence or analysis of legislation to mortality change. There can be no doubt that the ultimate arbiter of success is mortality change. Fig. 1 compares death rates from lung cancer in males in Finland with those of Hungary. The stark difference displays the effect of serious social and political policy plus educational activity as against that of prolonged apathy and failure to control tobacco industry marketing activities. As evidenced by Finland and other developed countries, when a comprehensive anti-tobacco policy is applied, it works.
Section snippets
Historic policy
The origin of the comprehensive tobacco policy owes much to the small group of British physicians behind the 1962 publication of a report on tobacco sponsored by the Royal College of Physicians [1], to the thinking behind the Norwegian Tobacco Act of 1975 and to ‘Guidelines for smoking control’ sponsored and published by the Union Internationale Contre le Cancer (UICC) [2]. Essentially that policy focussed on total prohibition of tobacco promotion; public education including packet labeling
The low tar, low nicotine policy
The policy of reducing tar (and nicotine) yields of cigarettes had a logical foundation. There was a dose–response between cigarette dose [5] and cancer risk and between the dose painted on mouse skin [6] and the ensuing cancers and there was reduction of risk with cessation [5]. It was reasonable to assume that reducing particulate content of cigarette smoke would reduce risk [7]. However, it was not possible to predict, at that time, that tobacco manufacturers would make qualitative changes
A modern approach to harm reduction
The low tar program was an attempt to make the cigarette less dangerous. We can learn from past failures and still look to achieve this to whatever degree possible. Clearly, it is possible to set upper limits for a galaxy of toxins and carcinogens [14], [29], [30] by simply setting the market median as an upper limit and allowing time for this to be met. Further reductions based on the same principle should follow. This should be carried out regardless of what is done about nicotine. Ventilated
Cessation policy
Cessation of smoking by use of psychological and therapeutic support commands lip service from governments and physicians, but is a cornerstone of policy. The use of psychological support systems goes back at least five decades to the well known ‘Five-day plan’ of the Seventh Day Adventist Church. It has been the subject of much competent research into behaviour and into the development of non addictive forms of clean nicotine suitable for use as tobacco replacement therapy (NRT). In many
Modern policy issues
Recent advances in knowledge have allowed focus on the chemistry of tobacco smoke and of nicotine addiction to a greater degree, opening up a whole new area of need—the control of carcinogenic and toxic components of cigarette smoke as an approach to harm reduction, as well as the need for a policy approach to nicotine delivery by cigarettes, as set out above. Further, the issue of exposure to secondhand smoke has triggered court-cases in the US and Australia which have awarded damages to
Conclusion
The epidemic of tobacco-induced mortality is winding down in some developed countries, but is increasing with little interference in the developing world. The influence of the tobacco industry, together with its credibility, is decreasing. However, the after effects of the historical combination of corruption and apathy within the political and public health establishments cannot be allowed to continue and the medical profession, in particular, must show leadership in tackling what is the
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