© Oxford University Press 2007.
NEWS |
Public Support for Smoking Bans Diffusing to Developing Countries
Back in 2004, Massachusetts policy makers escalated their efforts to vaccinate the state's population against cancer—not with a pill or an injection but with a policy to ban smoking in all workplaces, including restaurants and bars.
Declines in secondhand smoke exposure from that effort—led by Howard Koh, M.D., a professor at the Harvard School of Public Health and the state's health commissioner until 2003, and Greg Connolly, D.M.D., who directed the Massachusetts tobacco control program until he also joined the Harvard faculty in 2004—will probably boost the tobacco control program's ability to limit cancer deaths in the long run, Koh says. Up to 3,400 people die from lung cancer induced by secondhand smoke in the United States each year.
Workplace smoking bans have also begun to appear throughout the world, which suggests that international efforts to pass clean indoor air laws are gaining momentum, Connolly says. Ireland was the first, with a total ban covering all workplaces in 2004. Norway, Italy, Malta, Sweden, Iceland, and the United Kingdom have since followed, albeit with more limited laws that allow workplace smoking in separate, ventilated rooms. France implemented a workplace ban in January this year, which extends to restaurants and bars next year. Also in January, the European Commission released a report titled Towards a Europe Free from Tobacco Smoke: Policy Options at the EU Level, which suggests that binding smoke-free legislation for all 27 member nations are likely to be adopted at some point in the future. Other countries with smoke-free polices currently include South Africa, New Zealand, Australia, Uganda, Bermuda, the British Virgin Islands, Bhutan, Uruguay, and Iran.
Meanwhile, many U.S. states are going smoke free. California was the first to impose limited bans on workplace smoking during the mid-1990s, while Massachusetts was the first to impose a comprehensive workplace ban extending to restaurants and bars, where secondhand smoke exposures are especially problematic. In recent years, no fewer than 17 states and hundreds of municipalities have introduced smoke-free laws covering more than 50% of the U.S. population, according to the Americans for Nonsmokers’ Rights Foundation, in Berkeley, Calif. Of these, six states—Hawaii, New Jersey, Ohio, Rhode Island, Washington, and Massachusetts, as well as the District of Columbia—have instituted comprehensive smoke-free policies that cover all workplaces, including restaurants and bars. Ten other states, including Tennessee, a major tobacco producer, are considering equally stringent legislation, the foundation reports.
What's driving the global trend? Cynthia Hallett, the executive director of the nonsmokers’ rights foundation, says local laws passed in the United States, Canada, and Australia beginning in the 1990s showed that tobacco taxes and workplace smoking bans could be enforced without economic hardship to restaurants and bars. Those efforts led to statewide programs, such as those passed by Massachusetts, and ultimately to the World Health Organization's Framework Convention on Tobacco Control. That treaty, currently ratified by 145 countries (but not by the U.S.), requires its members to restrict tobacco advertising, put warning labels on tobacco products, establish clean indoor air laws, and clamp down on tobacco smuggling.
The success of state and local programs, combined with the tobacco control treaty's obligations, prodded Ireland to take the plunge, Connolly says. "And when Ireland went, other governments started moving."
Luke Clancy, M.D., F.R.C.P.I., who directs the Research Institute for a Tobacco-Free Society in Dublin, says workplace compliance with Ireland's policy approaches 90%. "We’ve seen dramatic indoor air reductions in smoke particulates, benzene, and carbon monoxide," he says. "And we’ve also shown improvements in respiratory function tests among restaurant workers. So this proves the policy works. Not surprisingly, it's been very popular, not just with nonsmokers, but with smokers too."
Studies in the United States, Scotland, Norway, and New Zealand, like those in Ireland, show that smoke-free policies drive tobacco consumption down, according to an article by Koh, Connolly, and his Harvard colleagues published in the April 12 issue of the New England Journal of Medicine, entitled "Making Smoking History Worldwide." In Massachusetts, cigarette sales have fallen 50%, he says, because of both higher tobacco taxes and workplace smoking bans. In Ireland, 15% of smokers quit after the ban, with most reporting that the law helped them do so. Similar bans elsewhere have been associated with roughly 4% reductions in smoking prevalence, Koh says.
Comprehensive workplace bans are effective because they can drive cigarette sales down, Connolly says. In Massachusetts, the ban accelerated a decline in statewide cigarette sales, which are now half what they were when the state first started taxing tobacco in 1992. Connolly suggests that taxes account for one-third of that decline, while the ban contributed significantly to the rest.
In the United States, where antismoking campaigns have a long history, steady declines in cigarette consumption have been linked to falling rates of lung cancer, particularly among men, says Michele Bloch, M.D., Ph.D., a medical officer with the NCI's tobacco control research branch. During the 1950s, up to 70% of U.S. adults smoked, she says, compared with roughly 21% today. But these declines mask important disparities, she adds. For instance, while more than 90% of college-educated Americans don’t smoke, roughly 30% of those with a high school diploma or less do.
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Developing World Challenges
But that disparity pales in comparison with those in the developing world, where the antismoking battle is just now gaining momentum. Of the roughly 1.3 billion smokers in the world today, 800 million live in developing countries, where tobacco companies enjoy huge market opportunities, according to Connolly. By doling out money to politicians, these companies operate with impunity in developing countries, he says. Billboard tobacco advertising—banned throughout parts of Europe and North America—is common in Latin America, Asia, and Africa, where it's often clustered near playgrounds and schools.
Damon Moglen, vice president for international programs at the Campaign for Tobacco-Free Kids, a nonprofit advocacy group in Washington, D.C., says tobacco companies often target women, who make up just 12% of the developing world's smokers. "They use messages that were common in the United States 20 years ago," he says. "It's the old Virginia Slims approach—that a woman in her own right can smoke once she's arrived as a person." When developing countries move to ban tobacco advertising, companies shift strategy. In Indonesia, for instance, they sponsor rock concerts and get attractive young people to hand cigarettes out to the crowd.
At the same time, large tobacco companies have been moving production facilities directly into the developing world. Philip Morris, for instance, recently launched a joint venture with the China National Tobacco Company, a monopoly that supplies 1.7 trillion cigarettes to China's 350 million smokers annually. The deal allows Philip Morris to make cheaper Marlboros in China and gives its Chinese partner access to global distribution networks. "The deal makes for a health disaster," Connolly says. Meanwhile, tobacco sales provide China its largest source of tax revenue after income taxes.
To successfully fight tobacco use in developing countries, health officials must eradicate social norms that make smoking acceptable, he says. Groups involved in that effort—including (among many others) Harvard's public-health program and regional associations like the Asia Pacific Association for the Control of Tobacco, a 10-nation organization based in Taiwan—now invest heavily in local campaigns to destroy the myth of the Marlboro man. Pictorial labels displaying mouth and lung tumors on cigarette packs have been particularly effective, Bloch says (see JNCI, Vol. 99, No. 6, p. 423).
In short, a tipping point on global awareness of smoking risks appears to be taking shape, Koh and Connolly write in the New England Journal of Medicine. In the developed world, that awareness has triggered a dramatic increase in smoke-free legislation and sent tobacco companies farther into poor countries, where billions face heightened smoking risks. In the developing world, Lithuania, Uruguay, Bhutan, and Iran have imposed the toughest legislation—a reflection of strong leadership and commitment to tobacco controls from their national governments.
"[Most] developing countries clearly have to catch up," Moglun emphasizes. "But we’re starting to see growing efforts to help them do that—many countries need help to meet their obligations under the [international tobacco treaty]. We stand to lose a billion people to smoking in the 21st century. But hopefully we can turn those numbers around."
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J Natl Cancer Inst 2007 99: 423.
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