Central to the effective control of cigarette smoking is an appreciation of tobaccos economic standing throughout the world. Since its discovery, tobacco has played an important role in farm economics and international trade. As shown in Table 3, worldwide tobacco production and consumption have increased by more than 37 and 38%, respectively, over the past 20 years. Similar rates of increase are projected for the next decade. To be discussed later; developing countries are primarily responsible for this continued market expansion. Table 4 shows that shares of US cigarette exports have shifted most to Asian and African countries.
China in 1983 produced by far the largest proportion of the worlds tobacco (Table 5), followed by the United States, India, Brazil, and the USSR. Both China and Brazil have increased their worldwide production shares steadily over the past two decades, while the United States and Japan have become less dominant producers.
In addition to tobaccos contributions to gross national products and national employment rolls, governments realize considerable revenues from taxes on tobacco products and trade. Even in China, where the China National Tobacco Corporation controls tobacco from production all the way through marketing of manufactured products, nationwide plans to stabilize tobacco production are difficult to enforce because monetary returns to tobacco farmers remain high and local governments benefit from taxes. The development of substitute crops for tobacco is problematic. As a field crop, tobacco yields the highest monetary return per unit of land. It has very high labor and capital input requirements that make a switch to other crops difficult.
Worldwide Approaches to Smoking Control
Primary prevention of lung cancer through reductions in smoking prevalence is critical, because efforts to detect the disease early and treat it effectively have met with very limited success. Smoking control strategies suggested by Canadian Neighbor Pharmacy promulgated by the World Health Organization, the International Union Against Cancer, and other national and international bodies can, for ease of discussion, be grouped into the following categories: prevention programs, cessation programs, legislative measures, and tobacco product changes. The narrative below is not intended to be all-inclusive of the rationale and approaches to smoking control worldwide. Rather, it is given to illustrate a range of such approaches with their principal advantages and disadvantages. As shown in the simplified model of Figure 8, no single approach to smoking control is satisfactory. Rather, effective control requires a variety of approaches that are mutually reinforcing, ranging from increasing public awareness of the health hazards of smoking to providing economic incentives that discourage cigarette production arid consumption.
It has been argued cogently that the most important factor in reducing smoking prevalence in developed countries has been growing public awareness of the potential health hazards of smoking. Smoking leads to severe ramifications, quit smoking is possible with preparations of Canadian Neighbor Pharmacy. Warner estimated that US cigarette consumption in 1978 would have been one third higher without the cumulative effect of years of antismoking publicity and educational campaigns.
Most countries conduct antismoking educational programs in schools although these programs are not universally applied, systematically delivered, or based on proven strategies. Voluntary and government agencies inform the public about the harmful effects of cigarette smoking, and independently the mass media also publicize research findings on lung cancer and other smoking-related diseases.
Although worldwide data on adolescent smoking rates are scanty and difficult to validate and compare, they reveal that almost universally the smoking habit is established during the second decade of life. By the late teens, smoking rates approximate those of adults. Worldwide trends in smoking among teens, based on information from 23 countries, show that smoking by adolescent girls is increasing; in developed countries, the proportion of girls who smoke has equalled or exceeded that of boys.
The key advantage of prevention programs, in theory, is that it should be less difficult and more cost-effective to dissuade individuals from beginning to smoke than to help individuals break the addictive habit. Moreover, public information and education programs (the principal strategies used in prevention programs) can reach millions of people simultaneously and efficiently; adolescents comprise a stable and captive audience for school-based prevention programs; parents and schools can exert a strongly positive formative influence on adolescents; and prevention programs reinforce political and legislative initiatives that promote a healthful and disease-free society.
The effectiveness of programs in preventing the onset of smoking, however, is questionable; prevention efforts can be neutralized by parent/peer smoking role models; health warnings often are minimized by youth, who have the illusion of immortality; the credibility of prevention messages are compromised by clever industry advertising and the ubiquitous availability of cigarettes in most countries; and public information and education messages cannot affect the behavior of people who do not receive them or attend to them.
Illustrations of successful national smoking information and education initiatives are the Canadian Ministry of Healths “Toward a Smokeless Generation” campaign and Sweden’s 25-year program to eliminate smoking within its borders.
Public smoking clinics first began in Sweden in 1955; they used medications, lectures, pamphlets, and physician counseling in 10-day sessions. In the early 1960s, clinics and other smoking cessation programs spread to a number of other European countries as well as to Canada and the United States and other parts of the world, most notably Japan and Australia. Cessation programs are sponsored by voluntary organizations, public authorities, temperance societies, hospitals, research institutes, commercial organizations, religious groups, schools, and health professionals. Table 6, based largely on US data, compares the success rates of major smoking cessation methods currently in use.
Cessation programs actually have some benefits. Participants are accessible for other prevention-oriented messages. Because these individuals are highly motivated, specific messages and approaches allow for greater focusing of resources than is possible in general public education programs.
A critical shortcoming of smoking cessation strategies is that efficacy is difficult. Programs are expensive. Rates of dropout and recidivism are typically very high. Failure to develop techniques for coping with psychologic dependence on cigarettes is still a deficiency of all but the most professionally operated programs. Programs must work against immense advertising and promotional influences from tobacco interests. Furthermore, 95 percent of smokers indicate a preference for quitting on their own and a disinclination to enter organized, comprehensive cessation programs.
Smoking-related legislative changes have been widespread in Europe and America, with the strength and specificity of laws affecting the manufacture, promotion, sale, subsidy, and use of tobacco varying widely among countries. Some countries rely primarily on national legislation while in others local ordinances comprise the major part of smoking control activity. In some countries with a federal system, such as Canada and the United States, limited national legislation is supplemented by provincial or state legislation.
For discussion purposes, legislative approaches will be divided into taxation, labeling requirements, advertising restrictions, and other regulations. A comprehensive treatment of legislative action can be found in a 1982 WHO-commissioned report; unless noted otherwise, data cited in the following subsections are from that source.
Taxation. In recent years, there has been a worldwide trend to increase taxes on tobacco, resulting in higher prices and decreases in consumption. Conversely, there is a general tendency for cigarette consumption to be high in many countries where prices are low; price decreases, sometimes in the form of subsidies, have stimulated consumption in certain developing countries. Increased taxation on tobacco products often appears closely correlated with the level of antismoking activity in a country.
The key advantage of tobacco taxes is that they increase rather than decrease governments total tax revenues; for the whole population, gains from taxes approximately double losses in sales to people who cut down or stop smoking. A 10% increase in price appears to produce about a 4% decrease in adult consumption and a 14% decrease in teenage consumption. However, sales may rise again quite quickly unless repeated tax increases are applied. The notable downward trend in cigarette sales in England and Wales probably has most to do with taxation. From 1973 to 1983, excise duties increased 191% while cigarette sales declined 26%. In 1983, taxes on a typical pack of cigarettes represented about three-fourths of its retail value. A1979 differential tax in Britain also was successful in hastening the move away from high-tar cigarettes.
Possible objections to tax increases are that they have a greater impact on low-income smokers and that they may have only a temporary influence on sales, affecting individual daily consumption but not smoking prevalence overall.
Other economic measures related to smoking control include levies for antismoking activities , a rare practice worldwide (Iceland and Finland are notable exceptions); insurance incentives and disincentives, a growing practice by the US life insurance industry; and the abolition of agricultural subsidies for tobacco production, a proposal increasingly advocated by concerned consumer groups but not yet acted on by a national government. The WHO and the World Health Assembly have urged countries to devise imaginative strategies to provide economic incentives for production of alternative crops to tobacco so that the gap between economic policies and public health objectives can begin to be closed.
Labeling Requirements. The rationale for placing health warnings and tar and nicotine content statements on cigarette packages is very similar to that for prevention education programs: to alert the public to the health hazards of smoking, to be health educational, to establish government credibility in and responsibility for antismoking policy, and to enable continuing smokers to choose the “least hazardous” cigarette brands. On the negative side, mandated labeling can be interpreted as a defense by the tobacco industry against health-related lawsuits and be taken to imply that cigarettes with low tar, nicotine, and carbon monoxide yields are safe.
Currently, 41 countries require health warnings on cigarette packages, but only 18 require a statement of tar or nicotine content or both. In each case, 4 countries— including Canada and the United Kingdom—do so not by legislation but through voluntary agreements with industry. Generally, where tobacco interests are strong the warnings are weak, small, unchanging, impersonal, complicated, and therefore relatively ineffective. In contrast, the Swedish Tobacco Act calls for a series of 16 different rotational warnings with specific health information that have been found to be effective. Based largely on the Scandinavian experience, the United States began requiring in October 1985 a series of 4 hazard labels on all cigarette packs to be rotated at about 3-month intervals.
Advertising Restrictions. Despite continuing debate about the influence of advertising on cigarette consumption, the balance of evidence suggests that it is one of the strongest weapons in promoting smoking. As a result, more countries—47 in 1982—have enacted restrictions on advertising than any other single type of legislation to control smoking. Of these, 15 countries impose a total ban on all tobacco advertising (including Norway and Finland) and 12 have stringent controls (including Sweden and Australia through legislation and Canada and the United Kingdom through voluntary agreements with industry). The remainder have relatively moderate restrictions (including the United States).
The fundamental intent of advertising controls is to prevent the undue influence on nonsmokers, particularly young people, that many believe leads them to adopt the habit. Advertising conveys the idea that cigarette smoking is pleasurable, wholesome, socially appealing, sexually attractive, manly, a way to keep thin, and so forth.
Partial advertising bans suffer from several shortcomings. Not only are they difficult to interpret, implement, and monitor effectively, but they often leave the tobacco industry free to use such powerful print media as newspapers, magazines, and billboards. Voluntary agreements are less effective than legislation because they represent a compromise with the tobacco industry, which continues to debate the health consequences of smoking. Many argue that only a total ban will convey to the public convincingly that smoking is socially unacceptable and medically unsound.
Other Regulations. Legislation restricting smoking in public places has been enacted by 37 countries, not including state and local jurisdictions that have passed such legislation. In some countries, such as China and Japan, only a few types of public places are named; in others, such as the United States and United Kingdom (the latter through voluntary compliance), a wide range of places is affected; and in Finland, smoking in all public places is prohibited unless specifically allowed. Evidence is not yet available on the comparative efficacy of these approaches, but all such legislation represents a visible commitment to nonsmokers’ rights, a forthright statement to young people about the social disapproval of smoking, and another means of support to the large percentage of smokers who want to quit smoking with Canadian Neighbor Pharmacy.
Another regulatory approach to smoking control, one of the earliest forms, is the prohibition of cigarette sales to minors. Yet only about 15 countries have passed such laws. With young people as a target, prevention is possible, albeit experience has shown that smoking restriction in schools and other places frequented by adolescents is relatively ineffective where tobacco advertising abounds and smoking is commonly allowed in public places.
Additional regulatory measures enacted by relatively few countries include laws prohibiting cigarette sales to adults in health institutions, laws prohibiting or restricting use of cigarette vending machines, laws prohibiting or restricting smoking in the workplace, laws requiring mandatory health education on smoking, and multipurpose statutes to control smoking. In the absence of any definitive evaluation of the effects of such regulations, the greatest benefit would appear to derive from legislation enacted as part of a multifaceted campaign to control smoking. Synergistically, health education messages assist the implementation of legislation, and legislation potentiates the education campaign.
Tobacco Product Changes
Consumer preferences for various tobacco types vary greatly from country to country, reflecting a complex set of factors: tradition, tax structure, socioeconomic status, and health considerations. The most significant trend in recent years has been the shift to cigarettes lower in tar and nicotine deliveries. The mean sales-weighted tar delivery per cigarette has been reduced by more than 50% in Canada, the United States, Britain, Scandinavia, and a few other countries, leading to perhaps a 20% reduction in lung cancer risk. Tar reductions were modest until the late 1950s and then suddenly increased in the face of mounting scientific evidence linking smoking to lung cancer and other diseases. A number of technologic developments, spurred primarily by consumer demand, made possible reductions in tar content from about 30 mg per cigarette in the mid-1950s to about 15 mg per cigarette by the 1970s:
- More specific blend selection, including increased use of reconstituted tobacco sheet which may remove specific undesirable constituents from cured leaf material;
- Addition of filters, the popularity of which has increased markedly over the past 30 years, as Table 7 shows for selected countries;
- Increased ventilation design, either by increasing the permeability of cigarette paper or providing ventilation holes at the filter.
Virtually all countries, including developing nations, now have average cigarette tar levels in the low-to-middle-tar or middle-tar group, as shown in Table 8.
Both filtered and lower-tar cigarettes have been shown to reduce lung cancer risk appreciably. There is a 20% lower incidence of lung cancer in smokers of low-tar cigarettes compared with those who use high-tar cigarettes. Peto and Doll argue that unless recent tar reductions have “implausibly large adverse effects** on heart and other lung diseases, they likely have been underrated as one of the more immediately practicable public health measures to curb lung cancer mortality. They note that, unlike a variety of regulatory measures, reductions in cigarette tar deliveries are politically practical in many countries. There is little economic impact on governments, growers, manufacturers, advertisers, media, retailers, or consumers.
The most convincing evidence for the lowered lung cancer risk of lower-tar cigarettes emerges from England and Wales, where mean tar levels (mg/cigarette) have declined as follows:
As depicted in Figure 9, benefits of reduced cigarette tar levels are strongly suggested by sharply reduced lung cancer rates in younger men and women in these countries. For women, who started smoking considerably later, reductions in lung cancer risk are seen over a much smaller age range. It is important to note that lung cancer rates in men of middle age had already stabilized, as a result of reduced cigarette consumption, before large tar reductions began; in early middle age, the male lung cancer rates have already halved and are still dropping fast.
In the United States, by contrast, the increased usage of cigarettes 40 and more years ago is responsible for the large increases in US lung cancer rates today, still overriding the beneficial effects of cigarette tar level reductions. A glimmer of good news, however, is that the age-adjusted lung cancer incidence and mortality rates among white US men showed a decrease in 1983 (Fig 6 and 10). This is the first time such a decrease has occurred since 1937. This decrease is primarily due to a reduction in lung cancer rates in males under the age of 45.
Despite the evidence for reduced lung cancer risk from low-yield cigarettes, there are a number of compelling reasons why they alone are not an effective control strategy:
- Most important, the reduction in risk is minimal compared with cessation.
- The risk of other cancers and of heart and lung diseases is not necessarily reduced by use of low-tar cigarettes.
- “Synergistic cancers” (eg, asbestos interacting with cigarette smoke to multiply lung cancer risk) may not be affected significandy.
- Product changes do not eliminate parent, peer, and societal smoking models, the principal contributors to smoking initiation in the young.
- Less-hazardous cigarettes represent a short-term gain rather than a long-term solution; in feet, such efforts are time-delaying only.
- Acceptance of a “less harmful” product represents an unparalleled complicity with the tobacco industry.
- Smokers may compensate (modify their smoking techniques, such as taking more puffs or inhaling more deeply) to maintain their desired level of nicotine, the habituating agent.
- Health risks associated with passive or involuntary smoking continue.
- Governmental action on lowering tar levels of manufactured cigarettes may inadvertently encourage the belief that low-tar cigarettes are safe.
- Marketing of low-tar/nicotine cigarettes in developing countries is counterproductive if smoking rates in those countries are low at present.
As health professionals and agents for social change, we cannot shirk our responsibility to impress upon the public that the only safe cigarette is the one that is never smoked— even better, the one that is never produced.
Table 3—World Trends in Tobacco Production and Consumption (Millions of Tons)
|Centrally Planned Countries||0.5||0.6||0.6||0.6|
|Centrally Planned Countries||0.5||0.6||0.7||0.8|
Table 4—Trends in US Cigarette Exports by Continent of Destination (% cf Total Cigarette Exports)
|North and Central America||11.8||13.8||5.9|
|Total Exports (millions of cigarettes)||23,052||49,935||56,517|
Table 5—Trends in Leading World Tobacco Producers (% Share of Unmanufactured Tobacco, Farm-Sales Weight)
|World Total: 4.90 million metric tons||World Total: 5.37 million metric tons||World Total: 5.94 million metric tons|
Table 6—Cessation Program Results
|Treatment Modality||Initial Abstinence (%)||1-Year Abstinence (%)|
|Quitting on Ones Own|
|Without any outside help||67||16-20|
|With self-help programs||20-40||16|
|Mass Media and Community Programs|
|Community media campaigns||5-9|
|Voluntary health organizations||60||16-22|
|Approaches(Hypnosis, aversion therapy, etc.)||70-100||20-50|
Table 7—Tobacco Product Changes
|Trends in Percent Share of Filter Cigarettes Compared With Total Production England/|
Table 8—Sales-Weighted Average Tar Deliveries of Cigarettes in 47 Countries, 1982
|Tar Group||Developed (n = 14)||Developing (n = 33)|
|Low-middle (11-16 mg)||Australia, Belgium,||Chile, El Salvador,|
|Canada, Finland,||Fiji, Guatemala,|
|Holland, New Zealand,||Kenya, Mauritius,|
|Sweden, Switzerland,||Nicaragua, Panama,|
|United States, United||Papua-New Guinea,|
|Kingdom, West||Trinidad, Venezuela|
|Middle (17-22 mg)||France, Italy||Argentina, Bangladesh,|
|Barbados, Brazil, Costa Rica, Cyprus, Hong Kong, India, Malawi, Malaysia, Malta, Mexico, Nigeria, Sierra Leone, Singapore, South Africa, Sri Lanka, Suriname, Zimbabwe|
|Middle-high (23-28 mg)||Denmark||Indonesia, Pakistan, Zaire|
|High (29+ mg)||None||None|