British Medical Bulletin

British Medical Bulletin Advance Access originally published online on November 14, 2006
British Medical Bulletin 2006 77-78(1):123-136; doi:10.1093/bmb/ldl012

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Tobacco control: present and future

Robert West

Department of Epidemiology and Public Health, University College London, 2-16 Torrington Place, London WC1E 6BT, UK

Correspondence to: Department of Epidemiology and Public Health, University College London, 2–16 Torrington Place, London WC1E 6BT, UK. E-mail: robert.west{at}ucl.ac.uk.

	Abstract

Top Abstract Introduction What constitutes a tobacco... Tobacco control up to... The future of tobacco... Conclusion Conflicts of interest Biographical details Acknowledgements References

 
The history of tobacco control in the twentieth century can be summed up by the phrase ‘too little, too late’. The century saw the proliferation of the most deadly form of tobacco use: cigarette smoking. Until the 1970s, no government took serious action to protect its citizens. In fact, probably the most effective global tobacco control ‘strategies’ to date have not been motivated by health concerns: they have been inaccessible or uneconomic markets for tobacco companies and a cultural taboo on women smoking. Economic development has led to massive increases in male cigarette smoking in developing countries but even now <10% of women in non-Western countries such as China, Russia and India smoke. With ‘westernization’, this picture is changing. Without drastic action to get current smokers to stop, the annual rate of tobacco-related deaths will grow from 5 million in 2006 to 10 million in 2025. Without further action to prevent take up of smoking, the subsequent death toll will be even higher. The recently enacted World Health Organization (WHO)-initiated Framework Convention on Tobacco Control (FCTC) can mitigate this impending disaster but only if it is implemented according to the spirit and not just the letter of the articles contained therein. Specific tobacco levies in every country should be the primary means of kick-starting the process, with the proceeds being used exclusively to fund other tobacco control initiatives, including product regulation.

Keywords: tobacco control • smoking • smokeless tobacco

	Introduction

Top Abstract Introduction What constitutes a tobacco... Tobacco control up to... The future of tobacco... Conclusion Conflicts of interest Biographical details Acknowledgements References

 
Tobacco use killed ~5 million people in 2006 [1]. On current projections, this figure will rise to ~10 million in 2025 [1]. Many of those who are killed and many more who are not will suffer severe disability for a large portion of their lives (Table 1). Most of the disease and disability comes from smoking, although some results from the use of ‘smokeless’ forms, primarily preparations that are chewed or held in the mouth (‘oral’ tobacco). The goal of tobacco control is to reduce this burden of death and disease.

View this table: [in this window] [in a new window]   Table 1 Fatal and serious non-fatal disorders for which tobacco use is a known or probable cause or exacerbating factor

 
The obvious strategy is to make it illegal to manufacture or sell tobacco products, with harsh sanctions for those who break the law. With tobacco use endemic in society and such powerful commercial interests at stake, there is no political will to adopt this kind of measure. The nearest any country that has come to it is Bhutan where the sale of cigarettes has been made illegal. Therefore, other means have to be found to reduce tobacco-related harm.

	What constitutes a tobacco control strategy?

Top Abstract Introduction What constitutes a tobacco... Tobacco control up to... The future of tobacco... Conclusion Conflicts of interest Biographical details Acknowledgements References

 
Tobacco control can involve (i) influencing the behaviour of current or potential tobacco users, (ii) limiting how far the tobacco industry can seek to influence their behaviour and (iii) reducing the harm from use of tobacco products.

Influencing the behaviour of users or potential users

Table 2 summarizes a simple taxonomy of approaches designed to influence behaviour patterns. This can provide a framework for understanding how existing tobacco control methods work and how they might be developed in the future.

View this table: [in this window] [in a new window]   Table 2 The epicure taxonomy of approaches to influencing behaviour

 
The aim here is to reduce the number of people who use tobacco by preventing young people from starting or motivating those who have started to stop. Using the taxonomy above, this can involve (i) education about the health effects of tobacco use and the benefits of stopping, (ii) use of persuasive techniques to foster negative attitudes to tobacco use, (iii) ‘quit and win’ type contests to incentivize smokers to stop, (iv) economic coercion through taxation and social coercion through public disapproval, (v) booklets, leaflets, Internet sites and so on providing instruction on how to stop successfully, (vi) prohibiting sales of tobacco to minors, restricting where people can smoke and so on and (vii) providing medication or psychological support for those wanting to stop tobacco use.

Limiting the activities of the tobacco industry

Curbing the tobacco industry’s efforts to get people to start smoking and not to stop could involve (viii) prohibiting marketing activities, (ix) preventing the industry from making unfounded claims about reduced health risks from products such as ‘low tar’ cigarettes and in principle (x) preventing them from engineering their products to make them more attractive or harder to give up.

Reducing harmful use

As noted earlier, smoking (including hand-rolled cigarettes, pipes, cigars and bidis) is by far the most harmful method of using tobacco [3, 12]. Smokeless products are two or more orders of magnitude less harmful, although they vary in this regard [11]. Nicotine itself appears to pose only minor risks to most people in the doses obtained from tobacco [13]; so, if one considers tobacco as primarily a means of ingesting nicotine, there is scope for reducing tobacco-related harm by (xi) introducing regulation to force the tobacco industry to reduce the delivery of toxins by their products and (xii) promoting switching from more harmful forms of nicotine ingestion to less harmful ones.

	Tobacco control up to the present

Top Abstract Introduction What constitutes a tobacco... Tobacco control up to... The future of tobacco... Conclusion Conflicts of interest Biographical details Acknowledgements References

 
Until recently, a major factor limiting the growth of cigarette smoking globally was probably the inaccessibility of markets or the lack of purchasing power in those markets, but this situation changed radically in the latter half of the twentieth century and continues to do so. Apart from this, the extent to which the 12 approaches listed above have been applied in different countries or regions has largely dictated the extent of tobacco-related harm experienced in those areas. The following paragraphs discuss approaches that have restricted growth in, or led to a reduction in, tobacco use, starting with what has had the most impact thus far.

Social coercion

Historically, by far, the most effective form of tobacco control has involved social coercion and in particular the existence of a strong taboo against women smoking. Even now, most of the world’s women face strong social pressures not to smoke, and smoking prevalence is much lower than in men [14]. In China, India and the Russian Federation, for example, smoking prevalence in women is <10%. Relaxation of this taboo in these societies represents a major threat to the world’s health [15]. The tobacco industry is exploiting this trend by aggressively promoting cigarettes to this new market [14]. In some regions in the West, such as California, it has been suggested that more subtle social coercion has played some role in the decline in smoking prevalence [16].

Education and persuasion

Education and persuasion have probably played a major role in decreasing smoking prevalence in some Western countries [17]. The effects of this kind of approach cannot be quantified by direct observation because there are so many potentially confounding factors. However, educating smokers about the harm caused by smoking and media advocacy and specific campaigns to shape social norms surrounding smoking were probably responsible for the downturn in smoking prevalence in the United Kingdom and the United States in the 1970s [18]. In these countries, mass media campaigns have probably had a much smaller effect in recent years [19]. However, this may reflect the modest budgets available to those devising the campaigns.

Warning labels on packaging and promotional material is another approach that is commonplace. A direct effect on prevalence following the introduction of warning labels has not been detected, but recent evidence suggests that pictorial warnings may have some impact [20].

Tax increases

Raising the cost of tobacco use has proved quite an effective tobacco control strategy [18, 19, 21]. On average, a 10% increase in the cost of smoking results in an estimated 4% reduction in the consumption of cigarettes (a ‘price elasticity’ of 40%). This figure is higher in developing than developed countries [18], higher in younger than older smokers [18], higher in lower income smokers [22] and higher in pregnant smokers than non-pregnant smokers of the same age [23].

A reduction in consumption does not equate to a similar size of reduction in smoking prevalence. Some of the decrease in consumption results from continuing smokers reducing the number of cigarettes they smoke per day. This would still represent a benefit, were it not the case that these people appear to smoke each cigarette more intensively and end up with the same amount of smoke exposure [24]. The effect of price rises on smoking prevalence appears to be over half the effect on total consumption [25]. In China, for example, the total elasticity has been estimated at 65%, with a ‘participation’ (prevalence) elasticity of 44% [26].

France recently increased the price of cigarettes by 40% in the space of just over 1 year. This was accompanied by a 31% decrease in consumption and a temporary doubling in calls to their smoking cessation helplines and purchasing of medications to aid cessation [27].

A major issue that arises in relation to tax increases is that of smuggling and tax fraud. In the United Kingdom, it is estimated that ~40% of cigarettes (including hand-rolled) have not had UK duty paid on them (and in most cases no duty of any kind) [28]. The average cost of such cigarettes is half of that of legitimate cigarettes [28]. Any taxation policy needs to be accompanied by vigorous and adequately funded law enforcement to combat this problem.

Smoking restrictions

Comprehensive bans on smoking in workplaces and indoor public areas also appear to have had an effect. The main reason for introducing such bans is to protect the health and comfort of non-smokers, but bans can clearly motivate smokers to try to stop and may make it easier for them to succeed. The recent ban in Ireland appears to have reduced smoking prevalence by 2% within the first 2 years [29]. A similar ban has been put into force in parts of the United States and Australia and in Norway, Scotland, New Zealand and Italy, with England due to follow in summer of 2007. Partial bans have been introduced in countries as diverse as Spain, India and Iran, although the degree of compliance and enforcement appears to be variable. Such partial bans appear to have minimal effect on smoking prevalence [18].

Provision of smoking cessation treatments

Increasing access to effective treatments to aid smoking cessation is an approach that has recently grown in popularity. The United Kingdom was the first country to introduce a national smoking cessation treatment programme funded through general taxation. Other countries have since followed suit, including Japan and Taiwan. Since 2000, in the United Kingdom, any smoker is entitled to receive behavioural support from a trained smoking cessation advisor or as part of a stop-smoking support group as well as a course of nicotine replacement therapy (NRT) or bupropion [30]. In addition, smokers can purchase NRT from pharmacies and some shops. In 2005, ~2 million smokers in the United Kingdom used NRT (and to a much lesser extent bupropion) to help them stop smoking, and the effectiveness of this treatment on permanent cessation can be estimated at ~2–3% (The permanent cessation effect is about half that of the 6-month continuous abstinence rates typically reported in meta-analyses.) [31]. In addition, ~600 000 smokers in the United Kingdom used medication plus behavioural support, and this will have helped an estimated 5% to stop permanently [32]. So treatment to aid cessation in the United Kingdom created ~90 000 ex-smokers in 2005. This represents 0.75% of the 12 million smokers in the country. Approximately one in four adults smoke, so the total effect on smoking prevalence will be ~0.2%. With less widespread access to treatment, the effect in other countries will be lower.

Restricting tobacco promotion

Many countries now restrict or ban the promotion of tobacco products. There is little evidence that restrictions short of a comprehensive ban have any effect, but comprehensive bans do appear to have an effect over time [18]. It seems likely that once the product has acquired a positive image among certain groups, that image is largely self-sustaining. Moreover, existing smokers do not need advertising to keep them smoking, most are addicted. However, in non-Western markets, banning all forms of promotion of tobacco products may slow the rising tide of smoking by preventing overt exploitation of the aspirations of these populations.

Restricting sales of tobacco to minors

Many countries do not permit the sale of tobacco products to minors (in the United Kingdom, for example, children <16 years) [18]. As currently implemented, it is not clear whether this measure has had any significant impact. One difficulty is that children often obtain cigarettes from older friends or siblings or from vending machines [33].

Stop-smoking materials

There is little evidence to date that booklets, leaflets or other self-help materials have a significant impact on tobacco use. A Cochrane review estimated a potential effect on cessation among those who use self-help materials of up to 1% [34].

There is now a burgeoning of Internet sites to help smokers to stop. Two recent randomized trials of an Internet site offering tailored support in smokers also using NRT showed evidence of modest but clinically and statistically significant effectiveness [35, 36]. A significant problem concerns the lack of quality control of stop-smoking Internet sites, and almost none of those that are in widespread commercial use has been evaluated in empirical trials or provide properly audited data on success rates, including those for which users have to pay.

Incentivizing smoking cessation

The most common form of incentivization of smoking cessation is the Quit-and-Win competition in which smokers register and then enter into a prize draw if they are abstinent at some defined future time point. There have been positive evaluations of this kind of approach [37], but there are concerns about the possibility of misuse, and thus far they have played a very small role in tobacco control strategies.

Preventing mis-claiming by the tobacco industry

After the failure to act once the harm caused by smoking became known, the ‘low tar story’ probably represents the biggest failure of tobacco control in the twentieth century. Once the health effect of smoking started to be publicized, the tobacco industry set about re-engineering its products to provide the impression that they were safer. Filters were introduced to trap the toxic tar droplets, and ventilation holes were punched into the cigarette paper to dilute the smoke. The tobacco industry marketed these ‘low-tar’ cigarettes in a way that was designed to reassure smokers, so that they would continue to smoke [38]. In fact, these cigarettes delivered to human smokers, as opposed to government smoking machines, roughly the same levels of toxins as the old cigarettes. This was because smokers simply adjusted the way they smoked to compensate for the changes [39].

The failure of governments to prevent the mis-selling of low-tar cigarettes probably resulted in many thousands of tobacco-related deaths of smokers who would have stopped had they appreciated the true harmfulness of the new products. Labelling brands with claims such as ‘mild’ or ‘low tar’ was recently banned in the European Union, but it may be too late now for it to have much effect.

Preventing engineering of tobacco products to promote addiction

Since its early days, the cigarette has changed radically to make it easier to smoke and more palatable while delivering nicotine rapidly in whatever quantity the smoker may desire. New evidence from studies in other species suggests that flavour and palatability may contribute in important ways to the addictive potential of the cigarette. It appears that nicotine is not strongly rewarding in isolation, but it makes other modestly pleasant stimuli that are associated with it much more powerfully rewarding [40]. Thus, it may be the combination of the sweet smell of tobacco and other sensations associated with smoking together with the nicotine ‘hit’ that is the lethal addictive cocktail. There has been no attempt to regulate the tobacco industry to prevent the engineering of cigarettes to make them more addictive.

Requiring the tobacco industry to reduce the harmfulness of their products

Inhaling tobacco smoke will never be anything other than very harmful. However, there are ways of engineering cigarettes to reduce the harm to human smokers. One method is to use tobacco that is missing some of the known carcinogens such as tobacco-specific nitrosamines. Another is to reduce the ‘tar-to-nicotine ratio’. If, as seems likely, smokers are seeking a particular quantity of nicotine, smoking can be made less hazardous by giving this to them with lower concentrations of other toxins [41]. The most extreme version of this would be a pure inhaled nicotine delivery device. Tobacco companies have begun to invest in producing what has come to be known as potentially reduced exposure products (PREPS), which are designed to deliver very low levels of tar [42]. However, they have not been forced to do so, and the pace of development has probably been slower than it would be if governments were to set low absolute limits on the delivery to humans of toxins in cigarette smoke.

Tobacco companies are also developing new oral tobacco products that can deliver high doses of nicotine relatively rapidly [43]. These are without question much safer than cigarettes, but there has been no pressure to develop these products from governments. On the contrary, this form of tobacco is banned throughout the European Union except in Sweden where it has been in widespread use for many decades.

Promoting switching to less dangerous forms of nicotine intake

No government has yet promoted switching to less hazardous forms of tobacco use. Many smokers in Sweden appear to have adopted the strategy anyway, and switching from cigarettes to snus (their particular form of oral tobacco) by millions of smokers has probably led to a reduction in smoking prevalence and tobacco-related deaths [44, 45]. The concern of some tobacco control advocates is that allowing the promotion of safer forms of tobacco use would undermine the efforts to encourage people to be entirely free from tobacco and might even, though a ‘gateway effect’, increase smoking prevalence [46].

	The future of tobacco control

Top Abstract Introduction What constitutes a tobacco... Tobacco control up to... The future of tobacco... Conclusion Conflicts of interest Biographical details Acknowledgements References

 
It is tragic but true that if we can just keep the number of tobacco-related deaths at their current level of ~5 million per year, then this will represent a major achievement in tobacco control. Unfortunately, we are extremely unlikely to be able to achieve even that goal. The reductions in deaths in countries such as the United Kingdom will be more than matched by massive increases in countries such as China. Globally, the biggest challenge facing the tobacco control community is to try to avert this impending disaster.

The global response to the threat from tobacco has been the Framework Convention on Tobacco Control (FCTC) (http://www.who.int/tobacco/framework/en/). This is the first ever global health treaty. It represents a landmark achievement that, if ratified and implemented, would without question prevent suffering and premature death of millions of people over the coming decades. Table 3 summarizes the main national obligations set out in the treaty.

View this table: [in this window] [in a new window]   Table 3 National obligations in the Framework Convention on Tobacco Control

 
To date, 168 countries have signed the treaty, and 137 have ratified it. At the time of writing, countries that have signed but not ratified it include Haiti and the United States.

Immense achievement as it has been to get this far, the impact of the treaty will be marginal without an even greater effort to ensure that its provisions are implemented in accordance with the spirit and not just the letter of its articles.

Comprehensive bans on promotion and marketing would have some impact, particularly in emerging markets. Smoking bans of the kind seen in Ireland could also have a part to play but will probably only be effective if the ground is prepared, so that there is widespread public support for them.

Probably the most important element of a tobacco control strategy in non-Western countries would be massive education and persuasion campaigns. This would be very expensive, and it is unlikely that these countries would feel able to expend the resources required to achieve this. The obvious way of kick-starting this process is for every country to impose a levy either on tobacco products or on tobacco industry profits, specifically for the purposes of funding tobacco control. A levy on tobacco would result in an immediate reduction in smoking prevalence. The funds could then be directed to tobacco control task forces in each country under legislation that would mean that they could not be clawed back by governments to spend on other activities. Concerns that such price rises could disadvantage the poor have probably been overplayed and in any event must be weighed against the substantial health gains in this group [47]. Treatment programmes to aid cessation have a useful part to play, and these could be funded by the levy.

If governments have the courage to do it, much stricter regulation of toxin exposure from tobacco products should be a major plank of future tobacco control. Existing and proposed regulations on smoke constituents from manufactured cigarettes are very unlikely to make a substantial difference because they continue to allow high levels of exposure to human smokers. Tobacco companies should be put on notice that beyond some designated timescale (e.g. 5 years), their products will not be permitted to deliver more than trace amounts of known carcinogens or other toxins. This can be achieved with smokeless products [48], so that such regulation could see the end of smoked tobacco as the dominant means of ingesting nicotine.

The other obvious source of funds for tobacco control is litigation. The history of attempts to get the tobacco industry to pay damages to healthcare systems or smokers suffering from smoking-related diseases is largely one of failure [49], but the Unites States scored a significant success with the Master Settlement Agreement in which many tobacco companies settled with 46 US states for more than $200 billion to be paid over 25 years.

Even in the United States, the legislative framework is far from conducive to civil action against the tobacco industry. Thus, the first step would be changing the legislative framework, so that the tobacco industry can be made to pay in full for the personal, social and economic harm caused by its activities. If every country in the world were to do this, it would represent a very significant step towards achieving the goals of the FCTC. Setting up this framework could be paid for by the kind of levy described above.

	Conclusion

Top Abstract Introduction What constitutes a tobacco... Tobacco control up to... The future of tobacco... Conclusion Conflicts of interest Biographical details Acknowledgements References

 
The history of tobacco control in the twentieth century can be characterized by the phrase ‘too little, too late’. Several decades elapsed from the demonstration that cigarettes are deadly to the point where any government felt it necessary to take serious action. It is only very recently that there has been adequate legislation to protect non-smokers from toxic exposure to cigarette smoke. No attempts were made until very recently to prevent the tobacco industry, pretending that they had developed safer cigarettes. There has been no serious attempt to regulate the products to make them genuinely safer. Treatments to aid cessation have emerged, but for most smokers in the world, they are too expensive or unavailable, and even where they are in widespread use, they can only have a small impact on smoking prevalence. Governments have mostly failed to undertake the kind of campaigns necessary to make its citizens feel genuine concern over the harmful effects of smoking. Until very recently, the tobacco industry has been allowed to market its products without regard to their inherent harmfulness.

Although some countries have succeeded in reducing adult smoking prevalence to <25%, the global picture is dismal. In the next 20 years, we will reap the grim harvest of the recent increase in male smoking in non-Western countries, and now we face the threat of a massive increase in smoking among women aspiring to what are seen as Western values. Success in tobacco control will be measured not by a reduction in tobacco-related deaths but by how far we can prevent these from increasing from their current figure of 5 million annually. FCTC offers a glimmer of hope, but only if countries around the world sign up to the spirit and not just the letter of the articles it contains. Doing this requires funds that most governments can ill afford.

Urgent attention needs to be given to kick-start the process with an immediate tobacco levy, the proceeds to go towards a coordinated tobacco control strategy that includes a substantial and sustained campaign of education and persuasion. Countries should also use the funds to prepare the ground for changing the legislative framework to make the industry pay for the harm it is causing. The tobacco levy, a tobacco control task force, extensive and sustained campaigns to educate and persuade smokers of the true costs of smoking, much stricter regulation of toxins delivered by tobacco products, denying the tobacco industry the opportunity to market their products and banning smoking in all indoor public areas and workplaces (Table 4) are measures that apply as much to Western countries such as the United Kingdom as to developing countries such as China.

View this table: [in this window] [in a new window]   Table 4 Seven elements of an effective tobacco control strategy

 

	Conflicts of interest

Top Abstract Introduction What constitutes a tobacco... Tobacco control up to... The future of tobacco... Conclusion Conflicts of interest Biographical details Acknowledgements References

 
The author undertakes research and consultancy and has received hospitality and travel funds from companies that develop and manufacture aids to smoking cessation including Pfizer, GSK, Novartis and Sanofi-Aventis. He also has a share in a patent for a novel nicotine delivery device.

	Biographical details

Top Abstract Introduction What constitutes a tobacco... Tobacco control up to... The future of tobacco... Conclusion Conflicts of interest Biographical details Acknowledgements References

 
Professor West graduated with a BSc in Psychology from UCL in 1977; then, after 2 years in the civil service, he returned to UCL to do a PhD, which he gained in 1983. As a postdoctoral researcher, he worked under Michael Russell at the Institute of Psychiatry studying the nicotine withdrawal syndrome. He left to become a lecturer, then senior lecturer at Royal Holloway, London University, from where he went in 1991 to St George’s Hospital Medical School where he was made professor in 1996. He was appointed to his current post as professor of Health Psychology and Director of Tobacco Studies at the CRUK Health Behaviour Unit, UCL in 2003. He researches patterns of smoking and smoking cessation and methods of encouraging and supporting smokers to stop.

	Acknowledgements

Top Abstract Introduction What constitutes a tobacco... Tobacco control up to... The future of tobacco... Conclusion Conflicts of interest Biographical details Acknowledgements References

 
The author is supported by a grant from Cancer Research UK.

Accepted for publication October 19, 2006.

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Top Abstract Introduction What constitutes a tobacco... Tobacco control up to... The future of tobacco... Conclusion Conflicts of interest Biographical details Acknowledgements References

 

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