Slowing the march of the Marlboro man

This week the journal reports the 40 year results from the world's longest running study of smoking and death, which finds that in Britain about half of all regular cigarette smokers will eventually be killed by their habit (p 901,1 p 9112). Next week more than 1000 delegates will attend the ninth world conference on tobacco and health in Paris. These provide an opportunity to take stock of the current status of tobacco and health worldwide.

The World Bank estimates that the annual tobacco consumption will remain stable between 1990 and 2000 at 1.9 kg per person aged 15 and over.3 That apparent stability masks two divergent trends: falls in tobacco use in the industrialised world and increases in developing regions.

Per capita tobacco consumption is expected to fall by 17% during this decade (from 2.4 kg to 2.0 kg a year) among the 35 “established market economies” of the world. At the same time per capita consumption is predicted to rise by 12% (from 1.7 kg to 1.9 kg a year) in the 180 “demographically developing economies.” Increases in con-sumption are also expected in five of the six formerly socialist economies of Europe for which the World Bank made projections.3

Smoking is responsible for three million deaths a year worldwide. If current smoking patterns continue that toll will have risen to 10 million deaths a year by 2025.*RF 4-6* Following trends in consumption, deaths attributable to tobacco will rise substantially in developing regions as deaths level off and then fall in industrialised countries.

Increases in tobacco consumption in developing countries reflect the marketing activities of the multinational tobacco companies. While tobacco markets shrink in the multinationals' home countries - the United States and Britain - the companies export their products, promotions, and political pressures to Asia, Africa, Latin America, and eastern Europe.7

In Taiwan free tickets to a rock concert are given to those who return empty packs of Winston cigarettes. In the Dominican Republic the Marlboro name and colours adorn road signs.8 In Moscow, where the city council has banned tobacco advertising, four adjacent, illuminated billboards advertise Western cigarettes in front of the Bolshoi Theatre.9 In Bucharest the amber filters of many of the city's traffic lights advertise the Camel brand.10 In Kenya BAT cigarettes are advertised between films in free mobile cinemas, without health warnings.11 These are just a few examples of the brazen tobacco promotions that are preying on some of the most vulnerable populations of the world.

But, as we bemoan this deplorable situation, we can take pride in the strong tobacco control programmes and policies that exist in many countries. Australia, Canada, Finland, France, Hong Kong, Iceland, New Zealand, Norway, Singapore, Sudan, Sweden, and Thailand are among the countries that deserve special credit. Some were among the early pioneers in tobacco control, while others have campaigns of more recent vintage. Some programmes are moderately strong but comprehensive, while others are strong in a few areas.*RF 12-14*

The United States has experienced an orgy of action against tobacco during the past 18 months. These events have created excitement in health circles because of their rapid pace and the great potential they hold for reducing tobacco use and countering the tobacco industry's iniquities. The changing climate surrounding tobacco has even spawned a best selling book of “fiction” about the tobacco industry.15 In the book the head of the tobacco lobby describes the industry's reality in the United States today: “It's a hostile world out there. I look around and all I see is muzzle flashes. What's more, I see muzzle flashes coming from where our friends sit.”

The muzzle shots began in January 1992. Two weeks before Bill Clinton was inaugurated as president the Environmental Protection Agency issued a report concluding that environmental tobacco smoke is a human carcinogen.16 Three weeks later Hillary Rodham Clinton announced that smoking would be banned in the White House. In April this year the Occupational Safety and Health Administration proposed rules that would ban smoking in most public places and worksites in the United States.17 Legislation was approved the following month by a congressional subcommittee chaired by Henry Waxman, chief sponsor of the proposal.

The Food and Drug Administration is contemplating classifying cigarettes as a drug. In testimony before Congress, commissioner David Kessler presented evidence that the tobacco industry has manipulated nicotine concentration in tobacco with the intent to create and sustain addiction in smokers.18 The Food and Drug Administration may use its authority to limit nicotine concentrations in tobacco, to restrict or ban tobacco advertising and promotion, and to regulate how and where cigarettes are sold.

The administration's investigation, along with internal industry documents leaked to the press, has resulted in several class action lawsuits being filed against the industry. One of these is a multi-billion dollar class action by 50 leading plaintiffs' firms, each committing $100 000 (pounds sterling 66 666) for the first year of litigation. The suit, based on alleged misrepresentation of the risks of smoking by the industry, seeks to establish a national trust for the lifetime medical costs of smokers funded by a share of the industry's future profits.19

In an unprecedented event in April the chief executives of the seven major American tobacco companies appeared as witnesses under oath before Waxman's subcommittee to answer questions about the Food and Drug Administration's allegations and their own leaked documents. Then, in May, several members of Congress asked the Attorney General, Janet Reno, to investigate whether industry executives were guilty of various criminal offences, including conspiracy to defraud the public and perjury before Congress. Reno later told the press that the Justice Department was looking into the allegations.

The states have also entered the fray. Three states - California, Massachusetts, and Michigan - have approved ballot initiatives that increased tobacco taxes and dedicated millions of dollars of tax revenue to tobacco control. Florida and Massachusetts recently approved legislation allowing those states to sue tobacco companies to recover government health care spending for disease attributable to smoking. Three other states - West Virginia, Mississippi, and Minnesota - have sued tobacco companies to recover such costs without specific enabling legislation. In 1993, $50 000m (pounds sterling 33 333m) spent on medical care nationally was attributable to smoking, 43% of which derived from public funding.20

Despite this feast of antitobacco proposals, pronouncements, and publicity the proverbial cup is still only half full. Most of the recent proposals are not yet final, and legal challenges to government actions are expected. The federal tax on cigarettes is still low ($0.24 (16p) per pack), and proposals to increase the tax to fund reform of the health care system have been scaled down drastically. Bills to ban tobacco advertising have languished for years. And the prevalence of smoking has levelled off recently (at 26% of adults) after a quarter century of steady fall.21

Delegates to next week's conference will share information and strategies on how to reduce tobacco use in countries such as the United States and Britain, where smoking has wreaked enormous harm. Another major focus of the conference will be the prevention of an epidemic of disease attributable to tobacco in countries where tobacco use is not yet widespread or longstanding.