• advertising and promotion
• advocacy
• global health

With this issue, Tobacco Control enters its fourth decade of publication, and the next issue will celebrate the journal’s first 30 years with a special collection of papers assessing the state of global tobacco control and the prospects for the future. But before moving ahead, it is sometimes useful to cast a look back. So I took a look at the very first 1992 issue of the journal, still available here: https://tobaccocontrol.bmj.com/content/1/1

Founding editor Ron Davis, who died age 52 years in 2008, editorialised in that first issue about ‘the slow growth of a movement’ seeking to address the world’s leading preventable cause of premature death. He noted that more than 50 000 biomedical journal articles had already been published on the topic of tobacco and health and subsequently reviewed in 8000 pages of 21 US Surgeon General’s reports. He reminded readers that the British Medical Association had asserted that ‘the battle over the evidence has been won’.1 Davis noted, in this regard, that the focus of research had shifted from investigations of the health effects of tobacco use to examining smoking behaviour and the impact of tobacco control interventions.

In 1992, US hospitals were for the first time being required to develop smokefree policies as a condition of accreditation.2 It seems bizarre now to recall that when I worked as a hospital nurse not terribly long before that, clinicians (including me, I regret to admit) still went into the utility room to smoke on cancer wards. Cigarettes were sold in hospital gift shops. Yet in some countries even today, hospitals are (shockingly) still not smokefree, and (more shockingly) even when hospitals have nominal smokefree policies, some clinicians remain unconvinced that they should not smoke with their patients or allow them to do so.3

In 1992, governments had barely begun to push back against the tobacco industry’s marketing, with some 20 countries banning tobacco advertising.4 The industry was noted to be pushing aggressively into lower income countries and regions, where awareness was low about how deadly its products were and are. Tobacco products have addicted and killed at least a hundred million more since then, most of whom started as children.

A paper by then-deputy editor Simon Chapman5 (who went on to become the journal’s second editor-in-chief and now editor emeritus) described a vigorous but ultimately unsuccessful campaign mounted by the tobacco industry to try to defeat an advertising ban in the Australian state of New South Wales. The messages used sound remarkably familiar all these years later: the proposed ad ban, according to the tobacco industry, would lead to lost jobs and suffering during an economic recession; would ‘criminalise’ honest workers; was neopuritanism and would be followed by bans on many other things; would take away freedom to choose; and was paternalistic. Chapman reported that the industry had commissioned several studies of public opinion, using questions that were just a teensy bit biased like: ‘As a nonsmoker, do you think tobacco companies sponsoring sporting events, the arts and concerts is likely or unlikely to make you take up smoking?’. ‘With the predictability of day following night, 98% answered unlikely’, Chapman acidly observed. Despite all the predictions of doom and the huge paid media campaign from the industry, the ad ban was enacted. The sky did not fall. Today, Australia is considered a ‘dark market’ with almost no tobacco advertising permitted. More than 30 years later, however, despite much progress, many countries still permit these lethal, defective products to be advertised.

A report in the same first issue described the 1989 US Federal Trade Commission report on cigarette advertising and promotion, which noted that such expenditures in the USA had increased by more than 97% across the previous decade, totalling some $3.6 billion in 1989.6 By 2020, that figure was $7.84 billion, most now spent on price discounts to cigarette retailers, an industry strategy to keep prices low despite tax increases. Distressingly, the 2020 report also noted the first increase in cigarette sales in 20 years—evidence the measures already taken in the USA are not sufficient to end the tobacco epidemic.7

The first issue also featured a summary of recent tobacco litigation.8 Richard Daynard described the beginning of the lawsuit brought on behalf of flight attendants who were exposed to secondhand tobacco smoke, a case that went on to make history, end smoking on airplanes and create a fund for medical research. Also discussed: the Rose Cipollone case, which dragged on for 5 years, long after the plaintiff’s death, but that landmark case presaged further litigation and first uncovered internal documents demonstrating tobacco industry fraud and deception.

In 1992, some hoped but few could have imagined how dramatically the legal and policy landscape would change and how large the tobacco control movement would grow over the next three decades. In subsequent years, the attorneys general of 46 US states and the US Department of Justice sued the major tobacco companies, resulting in the release of millions of pages of internal tobacco company documents that are still being used to help policymakers and the public understand the true origins of the industrially created, industrially sustained tobacco epidemic. From 2004, smoking was banned in pubs in Ireland, leading (and, at the time, flabbergasting) the world. The WHO Framework Convention on Tobacco Control (FCTC), the world’s first global public health treaty and one of the most widely embraced global agreements in the history of the UN, entered into force in 2005, with countries agreeing to institute a suite of tobacco control measures. To coordinate civil society support for effective implementation of the FCTC, the Framework Convention Alliance was formed, now comprising some 500 organisations from over 100 countries.9 Australia led the world in plain packaging and both Australia and Uruguay successfully defended against legal challenges backed by the tobacco industry. In many other countries, civil society groups organised to challenge the tobacco industry and enact public health policies. The tobacco industry increasingly became seen as a pariah.

Every single one of these events once seemed unimaginable, impossible or politically infeasible. Few in 1992 foresaw that governments really would ever dare to take on the tobacco industry itself, rather than continuing to focus primarily on politically palatable health education programmes and individual behaviour change. Few imagined that a civil society based tobacco control movement would achieve global stature and that those working to address other corporate determinants of disease would find lessons in the leadership of these pioneering tobacco control advocates.

But some pushed back against the power of the taken-for-granted, always the greatest obstacle to public health progress, and kept on pushing while many, many others gradually joined them. In doing so, they helped transform how we see the tobacco epidemic and aligned with new allies from communities most affected by it. There is likely hardly anyone now alive who has not experienced the loss or serious illness of a friend or family member sacrificed to tobacco company profits, though they may not yet realise that was the true cause of their loved one’s suffering or premature death.

Today, despite naysayers, doubters and continual industry interference, at last countries are beginning to develop plans to bring an end to the tobacco epidemic by addressing the structural, political and social dynamics that perpetuate it. Calls have intensified for governments to work towards phasing out sales of the most deadly tobacco products.10 While disagreements remain within the movement about the proper role of e-cigarettes and other nicotine products in the tobacco endgame, it is critically important to not let the tobacco industry prevail in undermining the FCTC and framing the agenda in its favour. Fights over what to do about this or that product must not be permitted to distract and fracture a movement of solidarity built over more than 30 years of hard-fought policy battles.

The industry plays a long game, but tobacco control is arguably stronger in this historical moment than ever before, with experience, tools, resources and power. Let’s try new things that no one 30 years ago imagined we could ever do. Let’s end this.