Global tobacco control policy
Global tobacco control policy
Abstract and Keywords
Tobacco control policy has evolved over time and will continue to do so. To every action by the tobacco industry there has been a reaction by public health authorities and vice versa. As a result there has been a continuing struggle between those committed to market expansion (the industry) and those committed to market shrinkage (public health authorities). This chapter considers the following issues: prevention of smoking initiation; management of addiction; regulation of the cigarette, the way it is sold, its nicotine content and its emissions; protection of non-smokers from second-hand smoke; public education and control of labelling and trademarks; disincentives to purchase (tax) and restrictions on sales to minors. The chapter will summarize what is, in effect, modern comprehensive policy.
Tobacco control policy has evolved over time and will continue to do so. To every action by the tobacco industry there has been a reaction by public health authorities and vice versa. As a result there has been a continuing struggle between those committed to market expansion (the industry) and those committed to market shrinkage (public health authorities). As a result the market is shrinking in most developed countries while it expands in many, but not all, developing countries. Between 1997 and 1999 world tobacco leaf sales went down from 7 975 360 tonnes to 6341430 tonnes (United States Department of Agriculture 2001), while world cigarette production went from 5 614 830 million pieces in 1996 to 5 573 464 million pieces in 2000 (United States Department of Agriculture, 2001). If public health is winning, it is winning very slowly. Fifty years of obstruction and obfuscation has maintained industry profits and seen a steady increase in global mortality (Peto 1994). To be effective, tobacco control policy must be comprehensive and global.
Making tobacco policy is not the same as implementing it and the time lag between the two processes is often decades. Tobacco use is, and will remain, one of the most difficult health issues facing society in the twenty-first century. It is worth reflecting on the history of the major infectious diseases and the disappearance from developed countries within a decade or less of smallpox, measles, diphtheria, tetanus, whooping cough, rubella, and scarlet fever. These diseases were conquered by the discovery, and use, of penicillin and vaccines that both worked and were used. Some of these diseases persist in developing countries for reasons related to social organization and money but NOT to organized opposition, which explains the slow progress against the tobacco epidemic. The single reason for the dominance of the tobacco problem is that someone is selling it, whereas no one is selling diphtheria or tuberculosis. This fact is unique to tobacco which has been, until very recently, the subject of a 50-year campaign of denial. By contrast, there was never a serious suggestion that asbestos did not cause asbestosis or that drunken driving was merely a pleasurable habit.
That the environment has changed is due to the effects of litigation, mainly within the United States, which has led to the arrival in the public domain of over thirty three million documents which revealed what the tobacco industry knew and when it knew it. The outcome of this process has been, at least in the case of Philip Morris (newly named Altria), a policy reversal which led to the admission set out in the following paragraph, which is a quote from their web site (Philip Morris USA, 2002).
Cigarette Smoking and Disease in Smokers: We agree with the overwhelming medical and scientific consensus that cigarette smoking causes lung cancer, heart disease, emphysema and other serious diseases in smokers. Smokers are far more likely to develop serious diseases, like lung cancer, than non-smokers. There is no ‘safe’ cigarette. These are and have been the messages of public health (p.644) authorities worldwide. Smokers and potential smokers should rely on these messages in making all smoking-related decisions.
This volte-face, accompanied as it is by a worldwide decline in the credibility of the industry, means that policy-makers are working in a completely different environment and that the task of proving the seriousness of the situation is less complicated, is more related to its magnitude, can focus on what needs to be done, and is much less of a debate. It does not mean that suggestions to governments go unopposed, or that the objective of market expansion has been abandoned by the industry.
This chapter will deal primarily with the cigarette, which is the most widely used and best-studied product. It should be noted that the remarkable mix of tobacco products that are smoked and chewed often in bizarre mixtures mostly in developing countries, pose singular difficulties, as they are usually regional, based on cottage industries and frequently not subject to tax, counting or inclusion in national statistics. The policy options available to deal with these are usually national and profoundly difficult to resolve. The bidi rolling industry in India exemplifies this. The role of women in the bidi rolling industry in India has important implications for the health of women but also bears on the economic ‘worth’ of women (it affects dowry negotiations). Since this industry also uses child labour when a village family undertakes a contract to a manufacturer it is clear that no simple solution exists.
Key policy issues include prevention of initiation; management of addiction; regulation of the cigarette, the way it is sold, its nicotine content and its emissions; protection of non-smokers from secondhand smoke; public education and control of labelling and trademarks; disincentives to purchase (tax) and restrictions on sales to minors. Many of these topics are covered in detail in the relevant chapters. This chapter will summarize what is, in effect, modern comprehensive policy.
Prevention of initiation
Prevention of initiation requires removal of all the positive stimuli to take up smoking and the provision of effective education which warns teenagers of the dangers of smoking without triggering a desire to experiment. This is not easy to do.
Removal of all forms of tobacco promotion is also not easy to do. Many countries have passed effective legislation to prohibit all forms of advertising down to and including point of sale advertising. This was achieved by straightforward legislation in Norway and Finland but in Australia (which is a federation) separate legislation (sometimes at state level, sometimes federal) was required for health warnings; broadcast media; billboards; print media; and point of sale. Sponsorship of sport was eliminated indirectly by prohibition of advertising of brand names, which also covered ‘brand stretching’ (or sale of other products using the brand name, and often trade mark) of the cigarette. Ultimately overall Federal legislation brought all these individual pieces together over two decades after the first law was passed for health warnings.
Not all countries have the power to totally abolish tobacco promotion. Both the United States and the European Union probably lack the powers to do so. No country can prohibit trans-national advertising such as accompanies the Formula One Grand Prix, both car and motor cycle, although individual countries can prohibit exhibition of brand names but then face the possibility that such events will be moved elsewhere. International sports advertising is ubiquitous and uses sports of wide interest such as car and motor cycle racing, cricket, golf, and soccer.
(p.645) Voluntary codes for advertising restriction have not been successful. However, if global advertising is to cease it can probably only be achieved by negotiation with the international tobacco industry under the sort of litigation-induced duress that brought about negotiations for a settlement in the United States in 1997 (Gray 1997). Such negotiations are only conceivable within a framework which envisages acceptance by both sides that the global tobacco market should shrink. Negotiation with the international television industry is another conceivable option but similarly difficult, though not impossible, to achieve.
The relationship between promotion and chemistry
While the contribution of advertising to initiation is undoubted, it is now evident (Wayne and Connolly 2002) that changes to cigarette design, particularly during the 1980s, led to the cigarettes intended for the ‘young adult smoker’ (YAS) and the ‘first usual brand young adult smoker’ (FUBYAS) being made significantly ‘smoother’ with characteristics of less ‘harshness’, greater ‘mildness’ and ‘lightness’, among other features. Camel, in particular, developed an advertising campaign using Joe Camel, the ‘smooth character’ in parallel with significant design changes that sent the cigarette’s chemistry in the direction desired by YAS and FUBYAS. Thus the cigarette became easier to smoke and easier to learn to smoke, and, as it had higher yields of nicotine, it may have become more addictive. Between 1987 and 1993, Camel’s market share among 18 year olds grew from 2.5% to 14%.
The market for cigarettes, and other forms of tobacco, is intensely competitive. While this persists abolition of promotion will remain extremely difficult. As a matter of policy, consideration needs to be given to replacing the open marketplace with a centralized, government controlled wholesale purchaser for cigarettes (Borland 2003), similar to the systems which operate in many countries for the purpose of purchasing pharmaceutical drugs. Such a body would then be in a position to specify what products it is willing to place on the retail market.
The role of packet labeling
The branded and trade-marked cigarette packet is a potent advertisement (Wakefield et al. 2000), whether featured on a billboard or as observable in almost any streetscape where a smoker, or a teenager, offers a friend a cigarette from a well-known packet. The packet is also a potent opportunity to give information ranging from explicit, research-based health warnings to the graphic and similarly explicit warnings pioneered by Canada. In the longer term a generic packet with suitable warnings is the only possible policy objective. This means abolition of trade marks, an objective that will not be easily attained.
Labelling with ‘tar’ and nicotine yields has been shown to be misleading in that the Federal Trade Commission (FTC) method of measurement does not represent the dose of smoke actually taken in by the smoker, and compensatory smoking is a frequent occurrence (Jarvis et al. 2001; Kozlowski et al. 2001; Benowitz 2001). For this reason alone use of these terms on the packet should be prohibited.
A second reason for abolishing these terms is the credible body of evidence suggesting that switching to low yield cigarettes has been seen by smokers as a viable alternative to quitting (Weinstein 2001). Further they have been used as justification for the use of terms such as ‘Light’ and ‘Mild’ (Pollay and Dewhirst 2002) which have, rightly, been prohibited by a number of countries.
This topic is covered in Chapter 39. There can be no doubt that modern techniques of counselling, associated with Nicotine Replacement Therapy (NRT) and more recently developed drugs can substantially increase quit rates. The current position is unsatisfactory in most countries in that NRT is more expensive and less available than the cigarette. A further problem is posed by the failure of the health professions to use available knowledge and therapy in a widespread way (Boyle et al. 2000).
This situation is regrettable and represents a seriously missed opportunity as cessation offers the most immediate return for health expenditure in terms of mortality reduction.
While abstinence from smoking is clearly the optimal approach, the concept of harm reduction is a logical approach to tobacco use (see Chapter 40). It can take three forms: reduction of risk by product switching; provision of nicotine to satisfy the addict’s needs by other products such as a nicotine replacement therapy that is truly competitive with tobacco – which means it would presumably be addictive – and modification of the tobacco product itself (by regulatory means).
♦ Product switching can undoubtedly be used to reduce risk at a personal level, for example a change from the cigarette to low nitrosamine smokeless tobacco. At a population level the value of this as a policy depends significantly on the national environment. In the United States there are many suitable lower risk products and much opinion supports product switching but, however, switching to another product that supports and maintains nicotine addiction leaves the smoker vulnerable to reversion to cigarettes. Further the tobacco industry has seen the marketing opportunities provided by product switching and has provided same name smokeless tobacco products ‘for when you can’t smoke’ and the possibility exists of the design of ‘starter’ smokeless tobacco products that might act as a gateway to smoking. Clearly the smokeless tobacco products used in Asia are totally unsuitable for reduction of risk, as they carry high risks of oro-pharyngeal cancers (Boffetta et al. 2008).
♦ Competitive nicotine replacement therapy could theoretically work, as well as switching to low nitrosamine smokeless tobacco and is very low risk apart from the serious potential to maintain nicotine dependence. However the pharmaceutical industry has not so far provided such a product for the probable reason that national regulators have given no indication that such a product would be acceptable and it is extremely likely that an addictive nicotine replacement therapy will only be produced when a major government asks for it. This is unlikely to happen while the international Tobacco Control movement remains divided on the issue.
♦ The first attempt to reduce the harmfulness of the cigarette was the policy of reducing tar and nicotine yields. This was logical at the time (the late 1960s) and should have been more successful than it was. Tar and nicotine reduction was subverted by the changes in design of the modern cigarette described by Hoffmann (Hoffmann et al. 2001). These changes involved increases in tobacco specific nitrosamines (TSNAs) which have been associated with increases in the relative and absolute risk of adenocarcinoma of the lung (Gray 2006). Together with other design changes (Kozlowski et al. 2001) which contributed to compensatory smoking the modern, low-yield cigarette, has not proven substantially less dangerous than its predecessor of 30–50 years (Thun and Burns 2001). The fact that the low-yield programme was not successful is no reason not to persist with attempts to regulate the content of cigarette smoke. (p.647) Two areas of regulation attract interest. Control of smoke levels of carcinogens and toxins, and control of the driver to inhalation, nicotine.
Control of carcinogens and toxins
The policy objective is to reduce as far as practical the levels of known carcinogens and toxins in smoke. Such regulatory control is best focussed on smoke content (the emissions) rather than the constituents of the cigarette even though certain substances, such as nitrosamines, may be best controlled at source – the nitrate levels in tobacco and the curing process. It does not seem sensible for governments to take responsibility for the design of the cigarette as the legal liability for design effects should remain with the manufacturer. While it is obvious that the ventilated filter is a serious problem there are ways of controlling emissions that are likely to lead to the industry abandoning it. Certainly removing tar, nicotine, and carbon monoxide measures from the packet would reduce the incentive to use filter ventilation.
Hoffmann has listed 15 major toxins and 69 carcinogens known to be in cigarette smoke (Hoffmann and Hoffmann 2001). Clearly these substances and certain other toxicants are prime candidates for reduction. A system has been proposed, based on analysis of cigarettes actually on the market now, by the Tobacco Regulation Study Group (TobReg) of the World Health Organization (WHO) whereby upper limits would be established for specified carcinogens and toxins in the emissions of tobacco smoke (WHO study group on tobacco product regulation, 2007). It is currently proposed to do the same for smokeless tobacco.
Such a regulatory system is practical now as some brands already on the market meet these criteria. There can be no justification for the continued marketing of cigarettes that are unnecessarily dangerous. If this form of regulation were to limit the number of brands available substantially, no harm would be done, cigarettes could still be sold profitably, and the harmfulness of cigarettes should be reduced. This in no way suggests that the cigarette could be ‘safe’ but it should certainly be less dangerous. Such an approach has been taken, successfully, to motor car exhausts.
Control of nicotine
Nicotine yields are currently measured by the FTC system, or something analogous. This system does not represent actual smoking patterns. A comparison of actual smoking patterns with the FTC method (Hoffmann and Hoffmann 2001) showed that smokers actually inhale between approximately one and a half to two and a half times as much nicotine, carbon monoxide, benz(a)pyrene, and 4-(methylnitrosamine)-1-(3-pyridyl)-1-butanone (NNK) than would be inhaled if the cigarette was smoked according to the FTC parameters.
Clearly, if nicotine dose is to be regulated, a better measuring system is needed. For regulatory purposes a simple measure of the amount of nicotine in the cigarette tobacco should suffice. However, if the smoker is to be informed of the dose he or she is getting, something much more complex would be needed.
Until now the dose given to the smoker has been determined by the cigarette manufacturer. The result is the carefully engineered (Kozlowski et al. 2001) modern cigarette which is smoked in a compensatory way. The degree of compensation occurring with this cigarette has not been meaningfully compared with the degree of compensatory inhalation that occurred three and more decades ago. It is probably greater. Clearly compensatory smoking delivers greater amounts of carcinogens and toxins to the lung and one object of regulation should be to reduce this.
The intricacies of nicotine policy are discussed elsewhere (see Chapter 8) and require consideration of nicotine in cigarettes and nicotine available in other forms. It is enough to canvass here (p.648) the possible options for the cigarette. The first policy requirement is that nicotine becomes the object of regulation. The options then become:
♦ Increase the amount of nicotine.
Providing a ‘satisfying’ amount of nicotine (which may mean an increase) has the advantage that it could be presumed to reduce compensation and therefore carcinogen/toxin dose (Russell 1976). The disadvantage is that it does nothing to reduce (and may enhance) dependence on the cigarette as a source of nicotine. Regulatory authorities are unlikely to be comfortable with this approach after several decades of struggle to reduce the dose.
♦ Allow the status quo
This has the disadvantage of leaving decision-making to the tobacco industry, leaves today’s level of compensatory smoking, and does nothing to reduce the addictiveness of the cigarette.
♦ Reduce the amount of nicotine
First proposed in 1994 (Benowitz and Henningfield 1994) this has the potential to reduce the addictiveness of the cigarette and the disadvantage that compensatory smoking might increase. It could only be done in parallel with a determined attempt to provide more widely available and efficacious NRT which might, used separately or together with cigarettes, replace the cigarette as the prime delivery system for nicotine. Clearly a major requirement would be a concerted comprehensive public education campaign. This option has possibilities in the long term but remains in the realm of the theoretical until nicotine levels in cigarettes are more universally captured by regulatory systems. The possibility of ‘more efficacious’ NRT being, or becoming, addictive, also needs to be faced.
Real control of dose and compensation
The above discussion of carcinogens/toxins and nicotine is aimed at reducing the amounts of the substances available per unit dose of smoke and need to be based on some form of standard measuring technique. The current FTC system is unsatisfactory and TobReg has preferred the Canadian ‘intense’ system and has phrased its recommended upper limits in amounts per milligram of nicotine. This takes some account of the smokers’ practice of compensating and also provides a larger quantum of smoke for measurement.
Secondhand smoke-the role of the smoke-free environment
The issue of exposure to secondhand smoke has more public health significance than is indicated by its direct effects on health. Since early publications indicating that such exposure was associated with increased disease risk (Colley et al. 1974; Harlap and Davies 1974; Hirayama 1981; Trichopoulos et al. 1981; Chilmonczyk et al. 1993) the non-smoking public has been a significant force in supporting reduction of such exposures. To a considerable degree, smokers have been compliant with attempts to restrict smoking opportunities and have even been shown to favour smoke-free workplaces (Hocking et al. 1991) and public places.
The policy of reduction of exposure to secondhand smoke has several important effects. The most important is that it contributes to reduction in smoking and in smoking rates (Chapman et al. 1999). The second is that it can be expected to reduce disease in those susceptible, particularly, to asthma. The third is reduction in lost work-time (Borland et al. 1997). An important factor in the establishment of the smoke-free environment has been successful litigation by employees suffering compensable diseases induced by secondhand smoke (Chapman 2001; Stewart and Semmler 2002). In Australia in 1997, 28% of smokers did not smoke at home (Borland et al. 1999). The insurance industry is an important ally in this area, as court cases involving the tobacco industry have been extremely expensive and settling out of court can be cheaper. (p.649) Further, after successful litigation, insurance of workplaces where employees are exposed to smoke becomes more expensive and may even be unobtainable.
Tax policy is a proven and long-established part of overall policy as it can be a strong disincentive to initiation. Cost also influences the amount smokers smoke, and contributes importantly to quitting (Manley et al. 1993). Taxes should be high to be as large a deterrent as possible, and may be responsible for a significant proportion of total government tax revenues. For example, they provided, in 1994–1995 4.34% of total tax in Argentina, 3.38% in Australia, 2.79% in China, and 2.43% in India (Sunley et al. 2000). Earmarking of a proportion of tax for health purposes is sensible and may be popular. Increasing tax to a point where it equals three quarters to two thirds of the price of cigarettes is regarded as achievable and appropriate (Chaloupka et al. 2000). Regular increases in excess of inflation are desirable and should be on every public health workers list of annual priorities.
There is a clear relationship between levels of consumer information and tobacco use, so the process of public education is an important element of comprehensive policy. In its simplest form, the provision of a health warning on the packet, provides a basis for further and more specific education campaigns. All available means should be used, including mass media (Friend and Levy 2002; Wakefield and Chaloupka 2000), and the best programmes should be based on relevant research in the population in question. Major educational interventions such as technical reports have important if short-lived effects (Kenkel and Chen 2000).
Sales to children, aged 16–18 are prohibited in many countries. Such prohibition is sensible but is rarely policed. Attempts are underway in the Unites States to remedy this. Until these attempts are shown to fail the policy remains important and should be seriously considered by developing countries.
What works is all of the above, together, as part of a comprehensive, planned, regularly reinforced exercise based on research within the society in which it is delivered, and policy initiatives should be regularly evaluated (see Chapter 37).
Clearly, everything cannot be done in every country at the same time but the fact that tobacco consumption is falling only slowly and that the manufacturers are successfully shifting their focus, and their recycled dishonest arguments, to developing countries can only be described as scandalous. Implementation if the Framework Convention on Tobacco Control, introduced as a treaty by the WHO needs to be supported vigorously by all countries. In particular, those countries where tobacco products are manufactured bear responsibility for what is exported, and countries that do not have local manufacture should avoid it and can more readily assert controls on what is allowed on to their market.
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