Elsevier

Lung Cancer

Volume 39, Issue 2, February 2003, Pages 113-117
Lung Cancer

Review
A global approach to tobacco policy

https://doi.org/10.1016/S0169-5002(02)00456-7Get rights and content

Abstract

The battle to control lung cancer has been an outcome of policies established over the years, largely since the 1960s. Early policies focussed on abolition of tobacco promotion, help in cessation of smoking, health warnings and labeling with tar and nicotine yields, public education, reduction of tar and nicotine yields, increases in tax and prevention of sales to minors. Over time the advent of nicotine replacement therapy, earmarking of tax for health purposes and counter-advertising became part of this policy. Over time the low tar policy delivered some but not all the benefits expected and the reasons for this are described. Modern approaches now feature regulation of the product with a reduction in the amounts of carcinogens and toxins in the smoke, a new measurement system for nicotine, a discussion of the options for nicotine policy and reduction of exposure to secondhand smoke.

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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