Tobacco Control and Primary Prevention

Historical Context of the Tobacco Epidemic

Tobacco is indigenous to the Americas, and, prior to its European discovery in 1492, tobacco was unknown in the rest of the world. After Europeans were introduced to tobacco—and nicotine addiction—consumption steadily grew in Europe. Despite its popularity, King James I of England issued “A Counterblaste to Tobacco” as one of the first documented efforts of tobacco control. In 1604, he not only stated the harm to the smoker as being “… hatefull to the Nose, harmefull to the braine, dangerous to the Lungs …” but also discussed the implications of second-hand smoke in the context of a woman whose husband smokes and “resolve[s] to live in a perpetuall stinking torment.” One of the first documented tobacco-control policies was his accompanying “Commissio pro Tabacco,” which levied a tax on tobacco importation. In these early years of the spread of tobacco, much of its use was in the form of chew tobacco, pipe tobacco, cigars, or snuff. Tobacco was even touted as medicinal. Despite the proclamation from King James I, government taxation, and various religious edicts, tobacco use continued to grow throughout Europe.

The Industrial Revolution included the development of cigarette-rolling machines in the late 1800s, which not only spawned mass production and increased the use of tobacco but also shifted the bulk of tobacco use to cigarette smoking. Cigarettes are smoked with deeper inhalation than pipe tobacco or cigars, leading to absorption in the pulmonary parenchyma rather than in buccal and pharyngeal parenchyma. As a result of pulmonary delivery, a much more rapid and intense peak in nicotine levels leads to a greater addiction potential. This more addictive product, combined with industrialization, global transportation, and aggressive marketing to men, women, and children across the globe, led to an explosion in tobacco use and a highly profitable industry.

The epidemiologic relationship between smoking rates in a population and death rates attributable to smoking has been extensively analyzed on a global scale, and fascinating patterns tend to recur predictably from one society to another. Lopez et al. noted that the rise in the prevalence of cigarette smoking was reflected in the rise in the death rate caused by smoking-related illnesses, with an approximately 20-year to 25-year lag. Overall, it has been demonstrated that death rates from tobacco-induced disease occur at a rate of roughly half of the smoking rate, given this time lag (e.g., for a population with a 60% smoking rate, 30% of the deaths 20 years later are secondary to smoking). Stage I of a smoking epidemic represents initiation, with low smoking rates and very low death rates due to smoking ( Fig. 2.1 ). Stage II consists of a rapid rise in the smoking prevalence among men to its peak, with the beginning of a rise in deaths. During this time, smoking among women just starts to increase, but there are few deaths. Stage III consists of a decline in smoking among men, with a continued increase in smoking among women. During this time, the death rate among men continues to rise following the 20-year to 25-year lag from the peak in smoking, and the death rate among women also begins to increase. Stage IV consists of a decline in smoking rates among men and a plateau or fall in smoking rates among women, with an eventual decline in death rates. The Lopez model has been applied to many societies, and, in general, developing nations tend to be represented by stages I and II, whereas many industrialized nations have experienced their peak in smoking rates and deaths, particularly among men, and are in stages III or IV.

This rise and fall in the number of smoking-related deaths closely parallels the rise and fall in lung cancer incidence and mortality rates in the United States. Smoking was relatively uncommon before 1900, correlating with Lopez stage I. The smoking rate among men in the United States increased from the 1900s and peaked around 1965 (stage II). After the Surgeon General’s report of the link between smoking and cancer, smoking rates among men decreased, yet smoking-related deaths among men continued to increase (stage III). This increase in male smoking prevalence eventually led to a peak and decrease in lung cancer–related deaths among men approximately 20 years later. During this time, the smoking rate among women rose and plateaued. In the late 1990s and beyond, the death rate among women was just beginning to decrease (stage IV). According to the Lopez model, the incidence of lung cancer and lung cancer–related mortality should continue to fall for men and women in the United States as smoking rates have declined.

This descriptive model has also been applied to many other societies. Rates of smoking in China and Japan have risen for men, and the rates of smoking-attributable deaths continue to rise in these societies (stage II). However, countries such as Australia, New Zealand, the United Kingdom, and Sweden have progressed through all phases of the Lopez model and are in stage IV, with declining rates of smoking-related deaths among men and women. Despite the decrease in tobacco use in some of the aforementioned countries, tobacco use is growing in other countries, particularly India, Japan, and China, where societal and cultural shifts are leading to growing numbers of people who smoke, particularly women. The growth of the global population, the spread of tobacco use to more countries, and the rising rates of smoking among women are all contributing to a projected rapid global increase in tobacco use and tobacco-induced deaths. The toll of tobacco is considerable, with an estimated 100 million deaths globally in the 20th century; currently, 5 million deaths are reported annually, with 1 billion deaths projected globally in the 21st century if the trajectory is not changed.

As smoking rates have declined in some countries, they have stabilized or increased in other countries as a result of aggressive marketing by the tobacco industry and lax or nonexistent tobacco-control policies. With the irrefutable evidence that this aggressively marketed, addictive product leads to premature death and disability among people who smoke (with one in two people who continue to smoke dying of tobacco-related disease) and illness in people exposed to secondhand smoke, tobacco control not only can be seen as a public health crisis but also can be viewed from ethical and human rights perspectives. By the end of the 20th century, the tobacco epidemic had steadily grown into a massive global crisis in which, currently, 5 million people die annually as a result of its use. Attempts at tobacco control have varied among different countries, and often by state or province within a country. The production, marketing, and distribution of cigarettes are predominantly controlled by a few international corporations: Philip Morris, Altria, British American Tobacco, Japan Tobacco, R. J. Reynolds, and China National Tobacco. The production, marketing, and distribution of cigarettes had become a globally organized network, and although the battle was being fought on many fronts, there was no global consensus on measures of tobacco control, and unified countermeasures to combat this problem were lacking.

21st Century Tobacco-Control Measures

The need for a comprehensive, unified, and enforceable global strategy to combat this global epidemic was initially conceptualized by Roemer and Taylor in 1993. These authors subsequently presented a strategy for a FCTC to the WHO in 1995. Persistent efforts led to adoption of the WHO FCTC at the World Health Assembly in 2003. The WHO FCTC came into force in 2005 as the first international treaty adopted under the WHO and was ratified by 177 parties in 2013. The United States notably remains a nonparty. This unprecedented agreement between party nations became the first international legal instrument for a unified approach to combat the global tobacco epidemic. The multidimensional treaty delineates universal standards declaring the dangers of tobacco and outlines strategies for limiting its use worldwide through provisions regarding education, production, advertisement, distribution, sale, and taxation.

The details of the entire WHO FCTC are beyond the scope of this chapter, but the WHO produced an internationally applicable summary of the essential elements of a tobacco-control strategy, publicized as the mnemonic “MPOWER,” which includes six components ( Table 2.1 ). Examples of successful tobacco-control strategies are discussed here using these categories as a construct.