Globe still in grip of addiction After five years, the World Health Organization’s tobacco-control treaty is starting to have an effect, but we

need to tackle the smoking epidemic in the developing world, say Jonathan M. Samet and Heather L. Wipfli.

At first glance, the past five years look like something of a triumph for anti-smoking campaigners, at least in the West. Legislation banning smoking in workplaces, bars and restaurants has helped to reduce tobacco use in many high-income countries. In Britain in 2008 just 22% of men smoked1, compared with 65% in 1948 (ref. 2). Furthermore, the rates of some major tobacco-related diseases are falling. In the United States, for example, the death rate from lung cancer in men has fallen by about 2% per year from 1993 and is no longer increasing in women3, and in the United Kingdom, the number of men diag-nosed with lung cancer has dropped by more than 45% from the peak in the late 1970s4.

Dig a little deeper, however, and the picture looks far from rosy. Decades after research first showed that active and passive smoking cause premature death, the world is still in the midst of an epidemic of tobacco-related illness. About 6 million people die each year because of tobacco, mainly from cancer, heart disease, stroke and chronic obstructive pul-monary disease, and without a rapid change in the epidemic’s course this figure is estimated to rise to 8.3 million by 2030 (ref. 5). The sub-stantial decline in smoking in the West has not happened elsewhere (see map): 1.2 bil-lion people worldwide — about 40% of men and 10% of women — are smokers6. Tobacco remains a very common addiction among men in many low- and middle-income coun-tries, although much less so among women. In fact, the proportions of cigarette production and consumption taking place in developing countries are rising by just under 1% a year7.

Clearly, more needs to be done to tackle the tobacco epidemic, espe-cially in the developing world. One of the most formidable obstacles to progress is the tobacco industry. Some transnational tobacco groups continue to challenge the scientific evidence that links passive smoking to death and dis-ease in non-smokers, and to use their immense financial resources to influence the political process, through lobbying, for example, and to challenge tobacco-control legislation in court. British American Tobacco (BAT) — the second largest transnational tobacco firm — has pushed to dilute legislation to keep public

places smoke-free8: in Argentina, the company is challenging the constitutionality of restrict-ing smoking in enclosed public places9. In China, BAT’s own documents show that the company had a strategy to divert attention away from the dangers of passive smoking10.

Captive marketsTobacco companies are still making huge prof-its and are likely to continue doing so for the foreseeable future. Developing countries —

particularly China, India and Indonesia, where about half of the world’s male smokers reside6 — offer huge markets, with hundreds of millions of men already addicted to

nicotine, and the prospect of many female cus-tomers. In China, where the majority of men but only a small percentage of women smoke11, the largest multinational tobacco firm Philip Morris has entered into a joint agreement with government-owned China National Tobacco Corporation (CNTC) to market its Marlboro brand12. Almost all the cigarettes in China are sold by the corporation.

Efforts to stamp out the global smoking epidemic have been under way for some time.

Five years ago this month, the World Health Organization’s (WHO’s) Framework Con-vention on Tobacco Control (FCTC) came into force. The 168 nations that have ratified it or its legal equivalent (that is, acceptance or approval) have committed themselves to a broad set of initiatives aimed at reducing tobacco’s harmful effects. The treaty addresses issues such as advertising and promotion, price and taxes, labelling, protection against second-hand smoke, education and cessation, illicit trade and sales to minors, and sets dead-lines for implementing measures to deal with them. In 2008, the process was reinforced by a package of six measures known as MPOWER, drawn up by the WHO to help countries cut demand for cigarettes. MPOWER focuses on improving monitoring, protecting people from second-hand smoke, offering smokers ways to stop, warning them of the dangers, enforcing bans on tobacco advertising and raising taxes.

The FCTC is a significant global campaign against the perils of tobacco. Even before it came into force, the process of negotiating it helped to foster a global network of research-ers, campaigners and public-health and other governmental officials working on tobacco control. Funding has been forthcoming,

“The effort to control tobacco contains many lessons for those tackling other lifestyle-related epidemics.”

AP

1020

Vol 463|25 February 2010

OPINION

1020-1021 Opinion - Tobacco MH.indd 10201020-1021 Opinion - Tobacco MH.indd 1020 18/2/10 19:11:0318/2/10 19:11:03

© 20 Macmillan Publishers Limited. All rights reserved10

too. The Bloomberg Family Foundation has pledged US$375 million through its Initia-tive To Reduce Tobacco Use, which supports tobacco control in low- and middle-income countries and gives priority to high-burden countries including China, India, Indonesia, Russia and Bangladesh. The Bill & Melinda Gates Foundation has donated $125 million, also aimed at control programmes in develop-ing countries. As the first global public-health treaty, some hoped that the FCTC might also be a template for tackling other public-health challenges, such as obesity.

So how successful has it been? The news is mixed. Many places have now passed comprehensive smoke-free laws. A new sur-vey of adults — the Global Adult Tobacco Survey, launched by the WHO and the US Centers for Disease Control and Prevention in Atlanta, Georgia, a few years ago — has greatly improved researchers’ ability to track the epidemic. Little progress has been made, however, in raising prices and taxes, the most cost-effective way to reduce tobacco use. Taxes are at the recommended 75% of retail price for only 6.2% of the world’s population. In China, cigarettes have become progressively more affordable since 1990 (ref. 13), and a recent tax increase did not affect prices because the CNTC held them steady14.

The FCTC is part of a global tobacco-control movement led competently by the WHO, yet this movement is not sustainable. Many coun-tries depend on external funding, some govern-ments remain reluctant to raise taxes and most governments are failing to take sufficient steps to persuade people to quit smoking. Only 8.2% of the world’s population has access to a quit-smoking hot-line and free access to some form of cessation service and nicotine replacement

therapy13. Unless the rate of quitting is quickly increased worldwide, tobacco-control measures will have little immediate effect on death rates.

Five steps forwardTo reduce global smoking and tobacco-related deaths worldwide, including stemming the power of the tobacco industry, we have the fol-lowing five recommendations. First, nations should deliver on the low-cost but effective obligations laid out in the FCTC: to protect the public from exposure to second-hand smoke and to place larger, more-effective warnings on cigarette packets. Second, barri-ers that are hindering price and tax increases need to be quickly identified and overcome. The power to do this lies with finance minis-tries, many of which seem to be reluctant to accept the findings from global studies that taxes are an effective way to control tobacco use without reducing revenue. Third, govern-ments need to put greater emphasis on help-ing people to stop smoking, using innovative, population-level approaches that will work in poorer areas, as well as more expensive clinical methods. Fourth, as deadlines pass for implementing FCTC measures over the next 5 years, government control programmes and tobacco-industry initiatives must be tracked. This should be done by the WHO through its annual reports, by the Conference of the Parties — the governing body for the treaty — through government reports, and by civil society through the Framework Convention Alliance. Finally, governments must take more responsibility for maintaining a tobacco-con-trol programme that will last for decades.

The effort to control tobacco contains many lessons for those dealing with other lifestyle-related epidemics, in particular the use of

strategies such as product labelling, the economic costing of disease and the limiting of advertis-ing and promotion. Health officials should also take heed of the tobacco industry’s attempts to diminish the scientific base for action, to influ-ence decision-makers, to interfere with policy-making and to target vulnerable populations, all tactics used by other multinational industries willing to sacrifice the public’s health for their profit15. The extent to which the FCTC is a suit-able model for other public-health treaties will become clear over its next five years. ■

Jonathan M. Samet and Heather L. Wipfli are

at the University of Southern California, Keck

School of Medicine, Department of Preventive

Medicine and USC Institute for Global Health,

Los Angeles, California 90033, USA.

e-mail: jsamet@usc.edu

1. Robinson, S. & Bugler, C. General Lifestyle Survey 2008 (UK

Office for National Statistics, 2008).

2. Wald, N. & Nicolaides-Bouman, A. UK Smoking Statistics

2nd Edition (Oxford Univ. Press, 1991).

3. Centers for Disease Control and Prevention. Lung cancer

trends (2009); available at go.nature.com/4PdC1V

4. Cancer Research UK. CancerStats Key Facts: Lung Cancer

and Smoking Statistics (2009); available at go.nature.

com/2BBv4T

5. Mathers, C. D. & Loncar, D. PLoS Med. 3, e442 (2006).

6 Shafey, O., Eriksen, M., Ross, H. & Mackay, J. The Tobacco

Atlas 3rd edn (Am. Cancer Soc. 2009).

7. WHO. WHO Report on the Global Tobacco Epidemic, 2008 —

The MPOWER package (WHO, 2008).

8 Corporate Accountability International. Protecting Against

Tobacco Industry Interference: The 2008 Global Tobacco Treaty

Action Guide (Corporate Accountability International,

2008).

9. Nobleza Piccardo S.A.I.C. y F. v. Provincia de Santa Fe

Unconstitutionality claim 188/2006, Corte Suprema de

Justicia de la Nación [Supreme Court] (Argentina).

10. Muggli, M. E., Lee, K., Gan, Q., Ebbert, J. O. & Hurt, R. D.

PLoS Med. 5, 1729–1769 (2008).

11. Yang, G. et al. J. Am. Med. Assoc. 282, 1247–1253 (1999).

12. Wright, A. A. & Katz, I. T. N. Engl. J. Med. 356, 1493–1496

(2007).

13. WHO. WHO Report on the Global Tobacco Epidemic, 2009:

Implementing Smoke-free Environments (WHO, 2009).

14. People’s Daily Online. Expert: Tax hike has little effect on

tobacco use (18 January 2010); available at go.nature.com/

pu7ad5

15. Michaels, D. Doubt is their Product : How Industry’s Assault on

Science Threatens your Health (Oxford Univ. Press, 2008).

A GLOBAL HABIT

2,500+

Per-capita cigaretteconsumption in 2007

1,500–2,499

500–1,499

1–499

No data

Cigarettes consumedin top five consumingcountries (billions)

Both per-capita and national cigarette consumption remain high.

China, 2,163United States, 357

Russia, 331

Japan, 259

Indonesia, 239

TOBACCO-RELATED DEATHS

2005

Total

Developing countries

Developed countries

200

180

160

140

120

100

80

60

40

20

0

2010 2015

Cu

mu

lati

ve

nu

mb

er

of

de

ath

s (m

illi

on

s)

Year

2020 2025 2030

SO

UR

CE

: TH

E T

OB

AC

CO

AT

LA

S

SO

UR

CE

: RE

F. 5

1021

NATURE|Vol 463|25 February 2010 OPINION

1020-1021 Opinion - Tobacco MH.indd 10211020-1021 Opinion - Tobacco MH.indd 1021 18/2/10 19:11:0618/2/10 19:11:06

© 20 Macmillan Publishers Limited. All rights reserved10