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Social justice recognises the need for the ‘the distribution of wealth, opportunities, and privileges within a society’.1 According to the United Nations, social justice is an underlying principle for peaceful and prosperous coexistence within and among nations.2 Social justice can also refer to the balance between individuals and society3; if we assume that governments play a major role in society, then their obligation to protect individuals from third parties4 (eg, the tobacco industry) becomes one of their key responsibilities in maintaining social justice. Furthermore, the actions of the government in one country can negatively impact social justice in another.
How is tobacco antithetical to social justice?
Tobacco is the leading cause of preventable death, annually killing more than 8 million people worldwide.5 These deaths are caused by the actions of the tobacco industry, an industry that has been allowed to impede social justice.
For decades, tobacco companies have been aggressively targeting certain vulnerable populations. For example, within the USA, African-Americans have been inundated with advertisements for menthol cigarettes.6 As a result, 85% of African-Americans who smoke use menthol cigarettes.7 As the Centers for Disease Control and Prevention (CDC) stated, ‘Although African Americans usually smoke fewer cigarettes and start smoking cigarettes at an older age, they are more likely to die from smoking-related diseases than Whites’,8 in large part due to compounding social inequities such as lack of access to healthcare and racism in the healthcare system.9 This is just one example of an intersection between social justice and tobacco. Commercial tobacco is also a barrier to social justice for youth,10 women,11 the lesbian, gay, bisexual, transgender (LGBT+) community,12 Indigenous people,13 people with lower income14 and people with less education.15
The tobacco-related burden of disease and death has also shifted from high-income countries to lower income countries, with over 80% of the world’s 1.3 billion tobacco users now living in low-income and middle-income countries.16 17 This in large part due to tobacco industry marketing, industry influence in policy making and aggressive litigation tactics.18 For example, some high-income countries allow tobacco corporations to manufacture cigarettes that were deemed unsafe for the market in their countries and export them to other, usually lower income countries.19 An investigative report concluded, ‘the cigarettes produced on Swiss soil and sold in Morocco are much stronger, more addictive and more toxic than those sold in Switzerland or France’.19 All of these burdens create a situation where the most vulnerable are left to deal with the consequences of tobacco use.
Intersections with other health/social justice issues
Highlighting connections with other health and social justice issues allows for partnerships with advocates in other fields and creates linkages for government officials, so they can further tobacco control and intersecting issues such as the non-exhaustive examples further.
Non-communicable diseases (NCDs)
NCDs kill approximately 41 million people each year, equivalent to 71% of all deaths globally.20 Tobacco use is the only risk factor shared by all four main categories of NCDs—cardiovascular disease, cancer, chronic lung disease and diabetes—and accounts for nearly one in six deaths from NCDs.21 In addition to the large-scale negative health impacts, NCDs reflect a challenge for social justice; 77% of all NCD deaths are now in low-income and middle-income countries.22
Women’s rights
Around the world, women use tobacco at lower rates than men.23 However, tobacco use among women is decreasing at a significantly lower rate,23 and in some countries, women are smoking more. For example, in France, between 1980 and 2012, despite a 6.3% decrease in smoking among men, there was a 75% increase in smoking among women and a nine times increase in tobacco deaths among women in 2010 than in 1980.24 25 Globally, women are still the main victims of secondhand smoke, and more women than men are harmed or die from exposure to it.26 Furthermore, unsafe work environments contribute to women dying from secondhand smoke, despite their being less likely to smoke themselves.26
COVID-19
During the COVID-19 pandemic, commercial tobacco and the actions of the tobacco industry are even more of a blight on society, as tobacco is a known risk factor for respiratory diseases and increases their severity. Many of the groups most harmed by tobacco are also at risk for worse outcomes when infected with COVID-19. African-Americans are more likely to contract COVID-19 and are 1.9 times more likely to die from it than white Americans.27 Lower income countries28 and people of lower socioeconomic status around the world29 have been, and still are, particularly vulnerable to COVID-19. Addressing tobacco can help protect these groups from both tobacco-related diseases and increased mortality risk from COVID-19.
Environmental justice
The ecological footprint of commercial tobacco is comparable with that of entire countries.30 From tobacco cultivation31 to cigarette manufacturing, distribution, consumption and the production of wastes and emissions (including cigarette butts and packaging waste), every stage in the global tobacco supply chain involves considerable resource inputs.32 Unfortunately, lower income countries and the most vulnerable communities bear the most burden.33
Recommendations
Commercial tobacco and the tobacco industry are harmful in myriad ways. We argue that a social justice approach to tobacco control can help counter these harms.
The Framework Convention on Tobacco Control (FCTC)
First and foremost, every country can and should become a Party to and implement all the measures of the FCTC. In addition, Parties should consider one article that is often overlooked, Article 2.1, which calls on governments to go further than the measures specified in the treaty ‘in order to better protect human health’.34 Some countries and governments have already accelerated the implementation of the FCTC by boldly implementing initiatives such as flavour bans,35 tax policies36 and standardised packaging37; some of these initiatives go as far as to ban the sale of commercial tobacco products, a movement that is gaining momentum.38 Other governments have already adopted ‘tobacco free’ or extremely low prevalence targets; for example, Finland has announced an action plan to achieve less than 2% smoking prevalence by 2040.39
Human rights mechanisms
In addition to using public health measures to end the tobacco epidemic, governments and civil society should employ the power of human rights mechanisms. There are several international human rights treaties that are relevant to tobacco control and social justice, and countries are obligated to report to those treaties about the human rights situation in their countries. However, those reports seldom include tobacco. The reports are submitted to the committee for each treaty, which in turn makes recommendations back to the country that submitted the report. Advocates have the opportunity to submit reports to draw each treaty committees’ attention to the way tobacco devastates the populations the treaties are bound to protect.
One study reviewed the Concluding Observation of the Committee on Economic, Social, and Cultural Rights. When a tobacco-specific parallel report was submitted, the Committee included tobacco in its concluding observations 28.9% of the time. When no parallel report was submitted, tobacco was mentioned a mere 7% of the time.40
Breaking down silos
Forming partnerships between tobacco and social justice movements is also crucial. The UN Human Rights Council adopted a resolution that encourages government parties to work across issue areas to achieve the right to health.41 Advocates can use this resolution to urge government officials to work across issues areas, for example, inviting local departments of both health and justice to support tobacco control policies.
Combatting tobacco industry ‘social justice’ messages
Tobacco corporations use corporate social responsibility (CSR) as a way to portray themselves as champions for social justice; for example, Altria recently gave a $5 million donation to ‘fight racial inequality’.42 FCTC Article 5.3 guidelines explain that the ‘tobacco industry conducts activities described as socially responsible to distance its image from the lethal nature of the product it produces and sells…’.43 Article 13 guidelines of the FCTC recommend banning CSR.44
A social justice approach can help counter these messages. Advocates in San Francisco framed their campaign to ban menthol and other flavours as a social justice issue, which resulted in an unanimously passed menthol restriction, despite industry pushback.45
Litigation
Social justice arguments add additional support to legal cases involving tobacco control. When a smoke-free air law in Peru was challenged, lawyers used human rights law (and focused on the right to health) to bolster their argument and ultimately won the case, leaving the law intact46 and protecting vulnerable people from secondhand smoke, a victory for social justice.47
Recently in the USA, several civil society organisations sued the US Food and Drug Administration (FDA) for its inaction on menthol cigarettes.48 In addition to the lawsuit, 96 organisations submitted a report to the Committee on the Elimination of Racial Discrimination to bring attention to the negative impacts of menthol on the rights of African-Americans.49 The goal of the report is to encourage the Committee to hold the US government accountable for protecting its citizens from the harms of menthol cigarettes. The legal arguments in the lawsuit against the FDA were largely based on human rights and social justice. The FDA agreed to propose a rule to ban menthol, and the court will continue to monitor its progress.50 This is an excellent example of how affirmative litigation can be fruitful both for tobacco control and to bolster social justice, as well as an example of how domestic tobacco control advocacy can be bolstered by a human rights approach.
Conclusion
Tobacco control and social justice are intrinsically connected. By addressing tobacco, we make progress towards a more socially equitable society. Tobacco control advocates should increase their use of tools that human rights and social justice advocates already frequently use: human rights treaty body reporting, international best practices (specifically the FCTC), litigation and legislation. These tools can help ensure that the right to health is protected for all people, but especially for vulnerable populations such as people of lower socioeconomic status, people with less education, racial minorities, the LGBT community and especially for those people who are at the intersections of these groups.
The body of knowledge at the nexus of social justice and tobacco control has grown by leaps and bounds in recent years. Now more than ever, it is apparent that by incorporating social justice and human rights language, arguments and mechanisms into tobacco control efforts, we can make progress to end the tobacco epidemic and improve social justice.
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Footnotes
Twitter @AshOrg, @brigittoebes
Contributors All authors contributed to the drafting and editing of this article and approved the final version for publication.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.