A BRIEF HISTORY OF TOBACCO USE: THE RISE OF MANUFACTURED CIGARETTES
The tobacco plant originated in the Americas and has been used by American Indians for over 2000 years. With the discovery of America, tobacco became available in Europe. In the sixteenth and seventeenth centuries tobacco was smoked in pipes, then it was taken as snuff, and by the nineteenth century it was smoked in the form of cigars [1]. Tobacco also quickly took hold in other parts of the world [2], being used in different forms such as bidis, which are made of tobacco wrapped in dried leaves, kreteks, which are clove-flavored cigarettes native to Southeast Asia, and water pipes, popular in North Africa. However, it was not until the invention of the manufactured cigarette, in the latter part of the nineteenth century, that smoking became a mass phenomenon. As can be seen in Figure 1, cigarette consumption greatly increased shortly after the introduction of the cigarette-rolling machine by James Bonsack in 1881, and it has been rising continuously since then [3,4].
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Figure 1. Worldwide cigarette consumption. |
The appearance of manufactured cigarettes in the late nineteenth century was accompanied by a steep decline in the use of other forms of tobacco. In the United Kingdom, for instance, as early as 1919 cigarettes accounted for more sales by weight than all other tobacco products combined [5], and this downward trend in the use of cigars and pipes has persisted to this day [6]. With the possible exception of chewing tobacco in India [7], the cigarette, either manufactured or in various hand-rolled forms, today represents the most prevalent method worldwide for consuming tobacco, and, owing to the form of delivery of tobacco (as smoke through the lungs), is arguably the most dangerous [8].
SMOKING AND NICOTINE DEPENDENCE
Although 70 to 80% of smokers would like to quit, and one third have made at least three serious quit attempts, the fact that less than half of smokers achieve abstinence in their lives [9] underscores the powerful addictive nature of tobacco. Though there are many different varieties of tobacco, they have one thing in common: nicotine, an alkaloid, which has pervasive effects on brain neurochemistry [10]. The addictive effect of nicotine can be enhanced by other tobacco additives such as ammonia [11]. Cigarettes have become popular because they have been designed to be particularly efficient nicotine delivery devices. A puff on a cigarette leads to the rapid absorption of nicotine into the bloodstream through the alveoli in the lung, and nicotine reaches the brain in less than 20 seconds [12]. The design of cigarettes allows for “fingertip control” over the dose of nicotine delivered, as smokers can adjust the intensity and frequency of puffing to suit personal preferences [13].
Nicotine creates dependence through the dual processes of operant conditioning: positive reinforcement rewards the behavior (ie, smoking) and negative reinforcement encourages the behavior in order to avoid unpleasant stimuli (ie, withdrawal symptoms) [13]. By binding to nicotinic acetylcholine receptors in the brain, nicotine taps into the central reward pathway (mesocorticolimbic dopaminergic system) that projects from the ventral tegmental area to the nucleus accumbens and prefrontal cortex [14]. The release of dopamine, a reward neurotransmitter [15], in the nucleus accumbens shell and associated areas as well as its interaction with other neurotransmitters is thought to mediate nicotine-induced positive reinforcement [16]. However, chronic exposure to nicotine also results in changes in the dopaminergic system: among others, there is a reduction in dopamine release and an increase in corticotropin-releasing factor during phases of abstinence [16], which are experienced as unpleasant withdrawal symptoms. Thus, smokers learn to smoke to relieve these symptoms. In addition, secondary sensory and behavioral cues (the lighting of a cigarette, the ensuing sensation, and stimulation in the mouth and throat, etc) act to reinforce smoking [17]. As smoking is carried out in a social context, there are a number of other sociocultural factors (eg, peer smoking, general acceptance of smoking) that have an influence [18].
Although operant conditioning operates outside conscious awareness, its psychological and behavioral consequences underline the addictiveness of smoking tobacco. Using standard definitions of substance dependence, smoking clearly fulfils most, if not all, of the criteria: difficulty in controlling use; a strong desire to take the drug; a great deal of time spent obtaining, using, or recovering from effects of the substance; continued use despite harmful consequences; and withdrawal; to name but a few. The highly addictive nature of tobacco was also acknowledged in the 1988 Report of the US Surgeon General [19], which concluded that “the pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine.” Thus, on the basis of current evidence, it is clear that tobacco dependence represents a very serious form of drug addiction and—considering the levels of worldwide cigarette consumption—one that is arguably unlike any other in the scale of its societal impact.
SMOKING PREVALENCE
Changes over the last century
As shown in Figure 1, cigarette consumption has increased consistently since the turn of the nineteenth century. However, cigarette consumption is not a perfect measure of population exposure, as there is no fixed relationship between the number of cigarettes smoked and the number of smokers because per capita values vary, depending on a number of factors including price and income. Prevalence, rather than consumption, figures are therefore arguably more relevant for public health purposes [20].
Unfortunately, data on smoking prevalence going back for more than 50 years are available for very few countries. In the United Kingdom, the first smoking prevalence figures were recorded by the tobacco industry and released in 1948, showing that 65% of men and 40% of women were smokers [5]. Over the following decades, prevalence among men peaked at 80% and decreased slowly, but it continued to rise among women, reaching 44% in the late 1960s. Prevalence figures then steeply dropped until the mid-1990s, when this decline started to level off, with smoking prevalence currently falling by less than 0.4% per year [21]. The scenario is broadly similar for most of the developed world; in the United States, for instance, cigarette consumption peaked at around 55% in men and 34% in women in the mid-twentieth century and has been decreasing steadily since then [3]. There is even less information about smoking rates in the developing world during the last century, and many countries have only recently started to collate data [2]. However, what evidence exists suggests that smoking prevalence in most developing nations or nations in transition steadily increased over the latter part of the twentieth century [22].
On the basis of these findings, a descriptive model (Figure 2) of the cigarette epidemic has been developed [20]. This indicates the rise of smoking prevalence up until 50 years into the epidemic, followed by a slow decline (more or less coinciding with the pattern observed in most of the developed world throughout the twentieth century).
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Figure 2. Model of the cigarette epidemic. |
Differences in prevalence by sociodemographic factors
Smoking and gender
Smoking prevalence tends to be higher among men than women. Globally, about 47% of men and 12% of women smoke, and four of five smokers worldwide are male [23]. Although men also tend to smoke slightly more cigarettes than women, studies suggest that women may be more nicotine dependent than men [24]. Moreover, in the developed world, this gender gap has been much reduced over the years, such that smoking prevalence of men and women has converged to within a couple of percentage points in countries including Sweden, Switzerland, and Australia [7]. By contrast, the gender gap in smoking prevalence in the developing world is still large, with five times more men than women smoking cigarettes, and this is most likely due to social and cultural stigmas attached to smoking among women [25]. Yet, changes in attitudes and targeted marketing by the tobacco industry are contributing to a likely rise in cigarette consumption in this group, and evidence is starting to emerge suggesting a steep increase in smoking prevalence among women in developing countries including Malaysia and Bangladesh [23].
Of particular worry is smoking among pregnant women, because of the teratogenic effects of nicotine [26]. Yet, in developed countries such as the United Kingdom, smoking prevalence in this group appears to have remained stagnant, if not on the increase, over the last decade. In 1999, as many as 30% of pregnant women were smokers [1]. The high smoking prevalence among pregnant women may in part be the result of the overall higher smoking prevalence among younger people (see the following).
Smoking and age
The vast majority of smoking is initiated before the age of 18, and many adolescents may start smoking by age 10 years or younger [27]. Current trends suggest that smoking prevalence among adolescents has not changed much over the last decade, and in some countries there is even evidence showing an increase in adolescent smoking rates [23]. Although men are overall more likely to be smokers than women, the picture is much less clear-cut when it comes to smoking prevalence among adolescents. In some European countries, smoking prevalence is higher among girls than boys [28].
Generally speaking, from early adolescence onward, smoking becomes more commonplace with an increase in age. Data from individual countries suggest that smoking prevalence usually peaks before middle age, around the mid-twenties in some countries [6] and somewhat later in other countries [29], and progressively declines from then onward. This pattern is mostly due to two factors: less dependent smokers start to stop smoking as they grow older, whereas those who are more dependent and continue to smoke start to die as old age approaches. Thus, overall smoking prevalence across the age groups takes a bell-shaped form, starting at low levels in young age, peaking in middle age, and ending at low levels in old age.
Smoking and socioeconomic status
Smoking prevalence tends to be strongly associated with socioeconomic status (SES), but the direction of this relationship is dependent on the stage of the epidemic. Smoking rates are initially higher among professionals and individuals with a high SES, as consumption at that point is primarily influenced by income. However, with growing awareness of the health consequences of smoking, higher SES smokers are more likely to successfully stop smoking than more deprived smokers, leading to an inverse relationship between smoking and SES. Lower cessation rates among poorer smokers exist for a number of reasons. These smokers are more likely to experience a lack of resources to aid smoking cessation. Other socioeconomic and psychosocial factors such as greater dependence in this group and greater likelihood of having a partner who smokes also contribute to their failure to stop smoking [30]. Indeed, data from countries in the latter stages of the epidemic suggest that, if anything, the gap between the lowest and highest socioeconomic groups has widened and that, although smoking prevalence was more than halved in the last 30 years in the most advantaged groups, it has stayed virtually unchanged among those who are most deprived [31].
Differences in prevalence by country
Data on cigarette consumption and smoking prevalence suggest a widening gap between high-income and low- and middle-income countries. As can be seen in Figure 1, cigarette consumption in the developed world has been reduced since the 1980s, and the opposite pattern can be observed in developing countries, where cigarette consumption has increased dramatically over the last 30 years. However, as a result of lower poverty levels, per capita consumption still tends to be higher in the developed than developing world [4].
Of the current 1.3 billion smokers worldwide, 1 billion live in the developing world, and it is estimated that in China alone there are 300 million male smokers [3]. Although the peak in smoking prevalence among men (though not in women) has been reached in the developing world, there remain stark differences in terms of male smoking. In countries including Guinea, Peru, Cambodia, and Russia, around 60% of men smoke, compared with a male smoking prevalence of 20 to 25% in Australia, the United States, and Sweden [23].
Following the model of the epidemic (see Figure 2), we can use these prevalence rates to allocate different countries to different stages [20]. Sub-Saharan Africa is currently at the beginning of the epidemic in stage I, as it displays relatively low male smoking prevalence and no or very few smoking-related deaths. Many countries in Asia (including Japan and China), Latin America, and North Africa find themselves at the next stage (II) of the epidemic, which is characterized by a dramatic increase in smoking prevalence and an early increase in female smoking, accompanied by a rising burden of smoking-related deaths. In stage III, both male and female smoking prevalence starts to decrease, but this decline is much less pronounced among women. At this stage, there is also a continuing rise in smoking-related deaths, and tobacco control efforts start to take shape as public acceptance of smoking begins to decrease. Most countries in Eastern and Southern Europe as well as some in Latin America would fall into this category.
The last stage (IV) of the epidemic is marked by a continuing decrease and, as already noted, convergence of smoking prevalences among men and women. At this point, smoking-related deaths among men also start to fall, though they continue to increase among women. During this phase, and in conjunction with public opinion turning against smoking, tax increases, smoking bans, and other tobacco control measures are being put in place. Most Western European countries and the United States, Canada, and Australia are commonly considered to have reached this stage. However, it should be noted that there are, of course, exceptions to the rule, and not every country strictly follows the progression of this model. In some Asian countries, for instance, the rise in male smoking prevalence has not been accompanied by a subsequent increase in female smoking, probably due to cultural factors. Nonetheless, the model does provide a useful and relatively simple way of charting the development of this epidemic and thus offers pointers on where and when to intervene to stop its lethal sequence.
Predicted trends in worldwide prevalence
As suggested earlier, the tobacco epidemic is still in its early stages in many countries, especially in the developing world, off-setting the decrease in consumption and prevalence observed in many parts of the developed world. For this reason, and also because of an assumed growth in the adult populations in the developing world, cigarette consumption is expected to reach about 9 billion sticks per year by 2025 (Figure 1). This means that even if worldwide smoking prevalence does not increase and remains at the current level of around 30% of the adult population, in just over a decade there will be 1.7 billion people, or 1.9 billion if an increase in income is assumed, who use tobacco products [4].
COST OF SMOKING
Health effects: impact on smokers
Smoking represents perhaps the single most important and enduring public health problem of modern society. Cigarette smoke contains over 4600 chemicals, 60 of which are known carcinogens [32]. Exposure to toxins such as nitrosamines and polycyclic hydrocarbons is responsible for the development of a variety of conditions ranging from neoplastic diseases like bladder cancer [33] to respiratory problems such as pneumonia [34]. Both the duration of smoking and the number of cigarettes smoked contribute to the occurrence of disease, though the length of time of smoking has a greater influence on disease incidence [35]. Smoking causes approximately 30 to 40% of all deaths among the middle age population and reduces a smoker’s life expectancy by an average of 10 years [36]. Longitudinal studies from the United Kingdom and the United States indicate that continuing smokers have more than a one-in-two risk of dying from smoking cigarettes [36,37]. The biggest killers for smokers are lung cancer, chronic obstructive pulmonary disease (COPD), and cardiovascular disease (CVD), which together account for approximately 70% of all smoking-related deaths worldwide [38].
Smoking causes between 20 and 40% of all cancer deaths, 70% of COPD-related deaths, and about 20% of deaths from CVD [35]. However, there exist some regional variations, and it appears that in developing nations a comparatively higher proportion of smoking-related deaths is attributable to COPD or tuberculosis than in the developed world, where the majority of smoking-related deaths are attributed to CVD [38].
Table 1 [39] provides an overview of fatal and serious nonfatal disorders for which tobacco use is a known or probable cause or exacerbating factor. As can be seen, smoking not only contributes significantly to global mortality but also to morbidity. For each smoking-related death, there are 20 smokers who suffer from comorbid, disabling diseases, most commonly respiratory or cardiovascular diseases or cancer [40,41]. In addition, a range of other nonfatal diseases are associated with smoking, including Crohn disease, ulcers, hip fractures, and cataracts [41]. Besides the physiological effects of smoking, there is also a well-established link between smoking and psychological disorders [42]. For instance, smokers are more likely than nonsmokers to suffer from schizophrenia, depression, and generalized anxiety disorder [43], and smoking has been implicated both as a consequence of [44] and a causal agent for [45] such mental disorders.
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TABLE 1. Disorders and diseases linked to tobacco use |
Altogether, tobacco use kills more people worldwide than the combined death toll caused by acquired immune deficiency syndrome, illicit drugs, and alcohol [46]. It is estimated that, in 2000 alone, smoking was responsible for approximately 5 million deaths globally [47]. However, owing to the late onset of illnesses like lung cancer [34], there is a time lag of about 20 to 30 years between the peak in smoking prevalence and smoking-related deaths (as shown in Figure 2). Thus, smoking currently contributes less to total mortality in developing nations (about 9%), where the tobacco epidemic is still at an earlier stage (II-III), than in developed nations (about 19%) [47]. If current smoking trends continue, smoking will become the leading cause of death and disability worldwide by 2020, when smoking-related deaths will reach 10 million per year. As a result of the increasing smoking prevalence in many African and Asian nations, the majority of these deaths (up to 70%) will occur in the developing world [3].
Health effects: impact on nonsmokers
Besides the physical and mental health impact that tobacco consumption has on the smoker, tobacco use also affects nonsmokers who either directly inhale environmental tobacco smoke or, as fetuses, ingest tobacco constituents in the womb. Research has shown a 15% excess health risk for nonsmokers living with smokers [48]. In the United Kingdom, for instance, the number of deaths caused by passive smoking, which included lung cancer, stroke, and ischemic heart disease, is estimated to have exceeded 10,000 in 2003 [49]. The effects of smoking on infants tend to be more insidious—there is a link between smoking during pregnancy and low birth weight, crib death, cognitive impairment, attention deficit disorder, and delinquency in later life [50].
Financial effects: impact on the economy
The direct and indirect health burden of smoking is very high indeed. However, smoking also has serious implications in financial terms. At the individual level, the cost of buying cigarettes can constitute a substantial proportion of household spending, especially in developing countries, thereby leading to increases in poverty [51]. At the population level, smoking causes immense costs not only in terms of additional health care, loss of productivity through absenteeism, and fires caused by smoking but also in terms of hidden consequences of smoking such as the diversion of agricultural land and environmental damage. For instance, yearly smoking-related health care costs are estimated to be around $2.3 billion in the United Kingdom and about $4.3 billion in China. Fires caused by smoking cost $27 billion a year worldwide [7]. However, this pales in comparison with the United States, where the overall yearly financial burden of smoking (including the indirect economic and socioeconomic costs) is estimated at more than $167 billion [52]. Evidence from around the globe puts health care costs at 1% of gross domestic product (GDP). The social cost of smoking accounts for a similar proportion of GDP, thus, even when adjustments are made for shorter lifespan in economic models, it is likely that, overall, there are still net costs associated with being a smoker [53].
Benefits of cessation
The health benefits of smoking cessation are considerable. Stopping smoking is arguably the single most important step people can take to improve their well-being. Quitting smoking can prevent tobacco-related diseases within only a few years of cessation; it halves the risk of contracting lung cancer [54] and has immediate positive effects on halting the occurrence and further development of various heart diseases [55]. Smoking cessation has been shown to attenuate lung function decline [56] and improve reproductive health [57]. Ex-smokers are significantly less likely to suffer from postoperative complications than current smokers [58], and there is evidence that quitting smoking may ameliorate mental health problems [59]. Altogether, it is estimated that up to 90% of excess mortality caused by smoking can be prevented if smokers stopped before they reached middle age [54], but even people who have smoked most of their lives can expect substantial health benefits when they stop smoking [60].
The positive effects of smoking cessation are not restricted to smokers themselves but also transfer to their surroundings through the reduction of environmental tobacco smoke. For instance, partners who live with ex-smokers are significantly less likely to develop cancer than those who live with continuing smokers, and mothers who stop smoking during pregnancy have healthier babies [61]. Last but not least, smoking cessation has economic benefits for the individual. This benefit will be particularly pronounced among poorer people in developing nations, who can ill afford the cost of buying cigarettes. Putting a stop to this diversion of critical resources means that they can instead spend available money on vital necessities [51].
TOBACCO CONTROL MEASURES
Common sense and current evidence suggest that the most successful strategies to reduce consumption and increase smoking cessation involve multiple approaches implemented in tandem within a comprehensive tobacco control scheme [9]. The most viable methods to achieve this aim will be briefly presented (some of which are discussed in more detail in Chapter 3 of this monograph) but it should be noted that most of the evidence in this area is informed by research carried out in the developed world and may therefore not translate one-to-one to developing countries.
Legislation and policy
Interventions at the population level, such as legislation and policy approaches, are particularly helpful because of their wide-ranging impact. Among these, taxation arguably stands out as most effective [62]. Taxation tends to display price elasticity of between -0.3 and -0.5; that is, for a 10% increase in taxes, there is an equivalent 3 to 5% drop in cigarette demand, and the effect of taxation in low- and middle-income countries is usually stronger than in high-income countries [6]. Another useful policy approach is the introduction of clean air laws, which has proven relatively effective when public and workplace smoking bans are comprehensive and are rigorously reinforced, having a similar impact on smoking prevalence as price or tax increases [63]. Marketing restrictions (advertisement ban, health warnings on cigarette packs, etc) also can be valuable but only if these policies are complete and comprehensive [64].
Research and public awareness
Dissemination of research findings through the involvement of health professionals and mass media campaigns has been instrumental in raising awareness of the smoking epidemic and instigating behavior change [6]. With an increase in awareness about the consequences of smoking, it becomes socially less acceptable, and public tolerance of smoking decreases, which in turn favors a positive climate for tobacco control activities [65].
However, research alone does not precipitate knowledge to the whole community because of a variety of sociodemographic factors. One important predictor of tobacco use cessation is education and the ability of people to access information [66]. Not only may smokers of lower socioeconomic status—given their stretched resources—feel that they have more urgent and pressing needs than smoking cessation, they also may be less aware of smoking-related health risks and the effectiveness of existing smoking cessation treatments than affluent smokers [67]. For this reason, more aggressive targeted media campaigns may be required. Long-term, intensive media counteradvertising campaigns seem to have the greatest overall impact on smoking prevalence, but this varies substantially, depending on the particular type of campaign employed [68].
Litigation and whistle blowing within the tobacco industry has been another effective approach at the disposal of tobacco control advocates for raising awareness in the public eye of the problem of smoking [69]. Litigation has not only provided access to secret internal tobacco industry documents, it also has weakened the economic position of tobacco companies, which had to pass the costs of litigation cases on to the consumer, thus directly leading to a decrease in consumption [70]. In addition, litigation and the action of whistle blowers can also increase pressure on tobacco companies to show social responsibility and can raise awareness of their unethical practices by drawing negative media attention [71].
Smoking cessation programs
Cessation and prevention programs encompass a whole range of measures to curtail the tobacco epidemic— ranging from the brief advice of health professionals to the intensive, multiple-session counseling of trained smoking cessation advisors. There is ample evidence for the effectiveness of brief advice provided by doctors, which has been shown to increase quit rates by about 2% [72]. Although this may not seem very much, brief advice has the potential to affect population smoking prevalence because of the wide reach of the intervention. There is also good evidence for the use of individual and group behavioral programs to increase abstinence rates, though it is unclear which component of these interventions is active [72]. Self-help interventions, which involve the provision of written material, quit kits, or audiotapes, have a small but significant effect on smoking cessation rates, as do telephone quit lines and tailored Internet-based programs [73]. These interventions also have the advantage of being very inexpensive.
In addition to behavioral treatment, a wide choice of medications is now available to help smokers quit. Nicotine replacement therapy (NRT) acts by replacing nicotine in the body, thus alleviating withdrawal symptoms, and by providing a control or coping mechanism to deal with the behavior change. NRT approximately doubles long-term abstinence [73]. Besides NRT, there are a number of non-nicotine pharmacological aids for smoking cessation. These include bupropion (amfebutamone) and nortriptyline, two antidepressants, which have efficacy comparable to NRT [73]. In contrast to NRT, however, they have the disadvantage of causing a number of unpleasant side effects. Another effective new pharmacological treatment is the selective partial agonist varenicline tartrate, which both mimics the action of nicotine in the brain (thus reducing withdrawal symptoms) and blocks nicotine from binding to nicotinic receptors (thus reducing the rewarding effects of smoking). Varenicline therapy has been shown to quadruple 1-year abstinence rates in comparison with no treatment [73].
CONCLUSIONS
Future challenges for tobacco control
Extrapolating current smoking rates and associated smoking-related deaths provides grim reading for the prospects of smokers. It is estimated that 100 million people died as a consequence of tobacco use in the last century (Figure 3). However, following present trends, this death toll will be easily eclipsed in the twenty-first century, when 1 billion people may die because of tobacco use [3].
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Figure 3. Estimated deaths from tobacco by intervention strategy. |
There is no question that over the last decades considerable progress has been made in tobacco control. However, the decrease in smoking prevalence in many developed countries has started to level off [23]. Moreover, prevalence in developing countries is rising, in part due to shifting perceptions regarding smoking among women and increases in youth smoking and in part due to a relatively underdeveloped tobacco control lobby that is faced by the aggressive expansion of tobacco companies in these countries [2]. Indeed, increasing globalization of tobacco companies has made it more difficult to control the expansion into new markets, and liberalization of tobacco trade has significantly raised cigarette consumption, especially in new markets [6]. Consequently, there remains an urgent need for a continued effort to better tobacco control—to develop new methods that prevent people from starting to smoke, motivate smokers to quit smoking, and sustain long-term cessation.
As can be seen in Figure 3, increasing worldwide smoking cessation rates represents the most effective means to prevent future deaths from tobacco use. This is because most of those who are likely to die in the next 40 years are already smokers now, and, although it is of utmost importance to dissuade young people from starting to smoke, this will have only a relatively small impact on the number of cumulative deaths in the first part of the twenty-first century [6]. In this scenario, halving the uptake of smoking by 2020 would prevent 20 million deaths, compared with no change in trend. In contrast, halving consumption by 2020 would save 180 million lives—the equivalent of the combined populations of Germany, France, and Spain—by 2050, compared with no change.
Obviously, each of the approaches to tobacco control— be they based on legislation and policy, research and public awareness, or smoking cessation programs—may differ in their effectiveness, depending on where and how they are implemented. Consequently, different countries may favor different methods to decrease smoking rates. However, especially for the developing world, where data on the smoking epidemic are relatively scarce and the level of knowledge regarding smoking is more limited, making the public aware of the health consequences of smoking through the gathering and publication of research evidence, mass media campaigns, and the involvement of health professionals will be a key issue [74]. Another future challenge for tobacco control is to widen access to effective smoking cessation programs through the provision of affordable behavioral and pharmacological smoking cessation aids, as those countries that are in most need of such interventions are also those with the least amount of money to spend on them [8]. Last, although all these interventions on their own can prevent many smoking-related deaths, it is the development of a comprehensive, coherent, and international approach to tobacco control that is most likely to have a palpable impact on the smoking epidemic. A promising start has been made with the introduction of a global tobacco control agreement, the Framework Convention on Tobacco Control (FCTC).
Framework Convention on Tobacco Control
The FCTC, under the auspices of the World Health Organization, is the world’s first public health treaty, and with its ratification in 2004 by over 40 countries, FCTC formally became international law in 2005 [75]. Currently, it has been signed by 168 countries and acceded to (that is, accepted as legally binding) by 152 countries. The FCTC provides a broad set of measures to reduce tobacco use. Ratifying countries agree to ban or restrict advertising, ensure sizeable health warnings on cigarette packs, ban deceptive labeling such as light cigarettes, ban smoking in indoor public areas and workplaces, tackle tobacco smuggling, encourage higher taxation to reduce tobacco consumption, regulate toxin delivery of tobacco products, require disclosure of tobacco product ingredients, consider litigation to force the tobacco industry to pay for the damage caused by their products, support smoking cessation programs and their inclusion in national health plans, and prohibit sales of tobacco products to minors as well as the distribution of free products.
The FCTC represents a global response to a global problem and ensures that lessons learned in the developed world can be quickly transferred to countries where the epidemic is still at an earlier stage, that is, to countries in economic transition or in the developing world. However, the success of the FCTC crucially depends on provisions to ensure its implementation both by civil society and individual governments. The FCTC is a unique tool to enable the application of the various tobacco control strategies at a worldwide level and to challenge the globalization of the tobacco industry. In light of the potential death toll from diseases caused by smoking in the twenty-first century, this is an opportunity that must not be missed.
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