Medical students in Jakarta demonstrate against tobacco a day before World No Tobacco Day, at Bundaran Hotel Indonesia, Central Jakarta, Indonesia May 30, 2010.
Tobacco control is a field of international public health science, policy and practice dedicated to addressing tobacco use and thereby reducing the morbidity and mortality it causes. Since most cigarettes and cigars and hookahs contain/use tobacco, tobacco control also concerns these. E-cigarettes do not contain tobacco itself, but (often) do contain nicotine. Tobacco control is a priority area for the World Health Organization (WHO), through the Framework Convention on Tobacco Control. References to a tobacco control movement may have either positive or negative connotations, depending upon the commentator.
Tobacco control aims to reduce the prevalence of tobacco use and this is measured with the "age-standardized prevalence of current tobacco use among persons aged 15 years and older".[1]
Connotations
The tobacco control field comprises the activity of disparate health, policy and legal research and reform advocacy bodies across the world. These took time to coalesce into a sufficiently organised coalition to advance such measures as the World Health Organization Framework Convention on Tobacco Control, and the first article of the first edition of the Tobacco Control journal suggested that developing as a diffusely organised movement was indeed necessary in order to bring about effective action to address the health effects of tobacco use.[2]
The tobacco control movement has also been referred to as an anti-smoking movement by some who disagree with its aims, as documented in internal tobacco industry memoranda.[3]
Early history of tobacco control
The first attempts to respond to the health consequences to tobacco use followed soon after the introduction of tobacco to Europe. Pope Urban VII's thirteen-day papal reign included the world's first known tobacco use restrictions in 1590 when he threatened to excommunicate anyone who "took tobacco in the porchway of or inside a church, whether it be by chewing it, smoking it with a pipe or sniffing it in powdered form through the nose".[4] In this restriction, tobacco was sentenced to excommunication, not so much because it harmed health, but because its use within the Churches was intolerable because it ruined the atmosphere of the masses. Thus, these sentences would not be made against tobacco per se (whose individual consumption was not penalized as long as it was moderate), but rather for its improper use in places considered sacred and public. The condemnation of improper use remains intact in Catholic doctrine today.[5]
The earliest citywide European smoking restrictions were enacted in Bavaria, Kursachsen, and certain parts of Austria in the late 17th century.
In Britain, the still-new habit of smoking met royal opposition in 1604, when King James I wrote A Counterblaste to Tobacco, describing smoking as: "A custome loathsome to the eye, hateful to the nose, harmeful to the brain, dangerous to the lungs, and in the black stinking fume thereof, nearest resembling the horrible Stigian smoke of the pit that is bottomeless." His commentary was accompanied by a doctor of the same period, writing under the pseudonym "Philaretes", who as well as explaining tobacco's harmful effects under the system of the four humours ascribed an infernal motive to its introduction, explaining his dislike of tobacco as grounded upon eight 'principal reasons and arguments' (in their original spelling):
First, that in their use and custom, no method or order is observed. Diversitie and distinction of persons, times and seasons considered.
Secondly, for that it is in qualitie and complexion more hot and drye then may be conveniently used dayly of any man: much lesse of the hot and cholerique constitution.
Thirdly, for that it is experimented and tried to be a most strong and violent purge.
Fourthly, for that it witherete and drieth up naturall moisture in our bodies, thereby causing sterrilitie and barrennesses: In which respect it seemeth an enemy to the continuance and propagacion of mankinde.
Fiftly, for that it decayeth and dissipateh naturall heate, that kindly warmeth in us, and thereby is cause of crudities and rewmes, occasions of infinite maladies.
Sixtly, for that this herb is rather weeed, seemethe not voide of venome and poison, and thereby seemeth an enemy to the lyfe of man.
Seaventhly, for that the first author and finder hereof was the Divell, and the first practisers of the same were the Divells Preiests, and therefore not to be used of us Christians.
Last of all, because it is a great augmentor of all sorts of melancholie in our bodies, a humor fit to prepare our bodies to receave the prestigations and hellih illusions and impressions of the Divell himselfe: in so much that many Phisitions and learned mean doe hold this humour to be the verie seate of the Divell in bodies possessed.
Later in the seventeenth century, Sir Francis Bacon identified the addictive consequences of tobacco use, observing that it "is growing greatly and conquers men with a certain secret pleasure, so that those who have once become accustomed thereto can later hardly be restrained therefrom".[6]
Smoking was forbidden in Berlin in 1723, in Königsberg in 1742, and in Stettin in 1744. These restrictions were repealed in the revolutions of 1848.[7] In 1930s Germany, scientific research for the first time revealed a connection between lung cancer and smoking, so the use of cigarettes and smoking was strongly discouraged by a heavy government sponsored anti-smoking campaign.[8][9]
Origins of modern tobacco control
After the Second World War, the German research was effectively silenced due to perceived associations with Nazism. However, the work of Richard Doll in the UK, who conclusively identified the causal link between smoking and lung cancer in 1952, brought this topic back to attention. Partial controls and regulatory measures eventually followed in much of the developed world, including partial advertising bans, minimum age of sale requirements, and basic health warnings on tobacco packaging. However, smoking prevalence and associated ill health continued to rise in the developed world in the first three decades following Richard Doll's discovery, with governments sometimes reluctant to curtail a habit seen as popular as a result - and increasingly organised disinformation efforts by the tobacco industry and their proxies (covered in more detail below). Realisation dawned gradually that the health effects of smoking and tobacco use were susceptible only to a multi-pronged policy response which combined positive health messages with medical assistance to cease tobacco use and effective marketing restrictions, as initially indicated in a 1962 overview by the British Royal College of Physicians[10] and the 1964 report of the U.S. Surgeon General.
In the United States, the 1964 report of the Advisory Committee to the Surgeon General represented a landmark document that included an objective synthesis of the evidence of the health consequences of smoking according to causal criteria.[11] The report concluded that cigarette smoking was a cause of lung cancer in men and sufficient in scope that “remedial action” was warranted at the societal level. The Surgeon General report process is an enduring example of evidence-based public health in practice.[11]
Comprehensive tobacco control
At the global level
The concept of multi-pronged and therefore 'comprehensive' tobacco control arose through academic advances (e.g. the dedicated Tobacco Control journal), not-for-profit advocacy groups such as Action on Smoking and Health and government policy initiatives. Progress was initially notable at a state or national level, particularly the pioneering smoke-free public places legislation introduced in New York City in 2002 and the Republic of Ireland in 2004, and the UK efforts to encapsulate the crucial elements of tobacco control activity in the 2004 'six-strand approach' (to deliver upon the joined-up approach set out in the white paper 'Smoking Kills' [12]) and its local equivalent, the 'seven hexagons of tobacco control'.[13] This broadly organised set of health research and policy development bodies then formed the Framework Convention Alliance to negotiate and support the first international public health treaty, the World Health Organization Framework Convention on Tobacco Control, or FCTC for short.
The FCTC compels signatories to advance activity on the full range of tobacco control fronts, including limiting interactions between legislators and the tobacco industry, imposing taxes upon tobacco products and carrying out demand reduction, protecting people from exposure to second-hand smoke in indoor workplaces and public places through smoking bans, regulating and disclosing the contents and emissions of tobacco products, posting highly visible health warnings upon tobacco packaging, removing deceptive labelling (e.g. 'light' or 'mild'), improving public awareness of the consequences of smoking, prohibiting all tobacco advertising, provision of cessation programmes, effective counter-measures to smuggling of tobacco products, restriction of sales to minors and relevant research and information-sharing among the signatories.
WHO subsequently produced an internationally applicable and now widely recognized summary of the essential elements of tobacco control strategy, publicized as the mnemonic MPOWER tobacco control strategy.[14] The six components are:
Monitor tobacco use and prevention policies
Protect people from tobacco smoke
Offer help to quit tobacco use
Warn about the dangers of tobacco
Enforce bans on tobacco advertising, promotion and sponsorship
Tobacco policies that limit the sale of cigarettes to minors and restrict smoking in public places are important strategies to deter youth from accessing and consuming cigarettes.[16] Amongst youth in the United States, for example, when compared with students living in states with strict regulations, young adolescents living in states with no or minimal restrictions, particularly high school students, were more likely to be daily smokers.[16] These effects were reduced when logistic regressions were adjusted for sociodemographic characteristics and cigarette price, suggesting that higher cigarette prices may discourage youth to access and consume cigarettes independent of other tobacco control measures.[16]
In December 2022, New Zealand became the first country to pass a bill that effectively raises the minimum age for cigarette consumption annually, in an effort to prohibit their sale to future generations. The bill specifically prohibits the sale of cigarettes to anyone born on or after 1 January 2009.[17][18][19] However, the law was later repealed before it could come into effect.[20]
Graphic warning labels
Some smokers are not fully informed about the risks of smoking.[21]Tobacco packaging warning messages which are graphic, larger, and more comprehensive in content are more effective in communicating health risks and knowledge about smoking.[22][23] Smokers who noticed the warnings were significantly more likely to endorse health risks, including lung cancer and heart disease.[21] In each instance where labelling policies differed between countries, smokers living in countries with government mandated warnings reported greater health knowledge.[24]
Graphic warning labels on cigarette packs are noticed by the majority of adolescents, increase adolescents’ cognitive processing of these messages and have the potential to lower smoking intentions.[25] The introduction of graphic warning labels has greatly reduced smoking among adolescents.[25]
Smoke-free public places
Smoking in indoor workplaces was first prohibited nationwide by the Republic of Ireland in 2003, with most other leading economies following suit with similar ordinances in subsequent years.
One of the clear "No Smoking" signs painted on the pavement leading to a small community park in Taipei, Taiwan
Smoking cessation
Smoking cessation services borrow from the methodologies of other addiction recovery interventions to assist smokers to quit. As well as reducing morbidity and mortality for individual patients, these have been repeatedly found to reduce the overall cost to health systems of treating smoking-related disease.
Reception and further international collaboration
Now an accepted element of the public health arena, tobacco control policies and activity are seen to have been effective in those administrations which have implemented them in a co-ordinated fashion.
The tobacco control community is internationally organised - as is its main opponent, the tobacco industry (sometimes referred to as 'Big Tobacco'). This allows for sharing of effective practice (both in advocacy and policy) between developed and developing states, for instance through the World Conference on Tobacco or Health held every three years. However, some significant gaps remain, particularly the failure of the US and Switzerland (both bases for international tobacco companies and, in the former case, a tobacco producer) to ratify the FCTC.
Journal
Tobacco Control is also the name of a journal published by BMJ Group (the publisher of the British Medical Journal) which studies the nature and implications of tobacco use and the effect of tobacco use upon health, the economy, the environment and society. Edited by Ruth Malone, Professor and chair, Department of Social & Behavioral Sciences, University of California, San Francisco, it was first published in 1992.
Opposition
Direct and indirect opposition from the tobacco industry continues, for instance through the tobacco industry's efforts at misinformation via suborned scientists [26] and 'astroturf' counter-advocacy operations such as FOREST.
↑ Royal College of Physicians "Smoking and Health. Summary and report of the Royal College of Physicians of London on smoking in relation to cancer of the lung and other diseases"(1962)
1 2 Anthony J. Alberg, Donald R. Shopland, K. Michael Cummings; The 2014 Surgeon General's Report: Commemorating the 50th Anniversary of the 1964 Report of the Advisory Committee to the US Surgeon General and Updating the Evidence on the Health Consequences of Cigarette Smoking, American Journal of Epidemiology, Volume 179, Issue 4, 15 February 2014, Pages 403–412, doi:10.1093/aje/kwt335
1 2 3 Maria T. Botello-Harbaum, Denise L. Haynie, Ronald J. Iannotti, Jing Wang, Lauren Gase, Bruce Simons-Morton; Tobacco control policy and adolescent cigarette smoking status in the United States, Nicotine & Tobacco Research, Volume 11, Issue 7, 1 July 2009, Pages 875–885,
1 2 Hammond D, Fong GT, McNeill A, et al. Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey Tobacco Control 2006;15:iii19-iii25.
1 2 Sarah D. Kowitt, Kristen Jarman, Leah M. Ranney and Adam O. Goldstein, Believability of Cigar Warning Labels Among Adolescents, Journal of Adolescent Health, 60, 3, (299), (2017).
A cigarette is a narrow cylinder containing a combustible material, typically tobacco, that is rolled into thin paper for smoking. The cigarette is ignited at one end, causing it to smolder; the resulting smoke is orally inhaled via the opposite end. Cigarette smoking is the most common method of tobacco consumption. The term cigarette, as commonly used, refers to a tobacco cigarette, but the word is sometimes used to refer to other substances, such as a cannabis cigarette or a herbal cigarette. A cigarette is distinguished from a cigar by its usually smaller size, use of processed leaf, different smoking method, and paper wrapping, which is typically white.
Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is believed to have begun as early as 5000–3000 BC in Mesoamerica and South America. Tobacco was introduced to Eurasia in the late 17th century by European colonists, where it followed common trade routes. The practice encountered criticism from its first import into the Western world onwards but embedded itself in certain strata of a number of societies before becoming widespread upon the introduction of automated cigarette-rolling apparatus.
Tobacco package warning messages are warning messages that appear on the packaging of cigarettes and other tobacco products concerning their health effects. They have been implemented in an effort to enhance the public's awareness about the harmful effects of smoking. In general, warnings used in different countries try to emphasize the same messages. Warnings for some countries are listed below. Such warnings have been required in tobacco advertising for many years, with the earliest mandatory warning labels implemented in the United States in 1966. Implementing tobacco warning labels has been strongly opposed by the tobacco industry, most notably in Australia, following the implementation of plain packaging laws.
Nicotine marketing is the marketing of nicotine-containing products or use. Traditionally, the tobacco industry markets cigarette smoking, but it is increasingly marketing other products, such as electronic cigarettes and heated tobacco products. Products are marketed through social media, stealth marketing, mass media, and sponsorship. Expenditures on nicotine marketing are in the tens of billions a year; in the US alone, spending was over US$1 million per hour in 2016; in 2003, per-capita marketing spending was $290 per adult smoker, or $45 per inhabitant. Nicotine marketing is increasingly regulated; some forms of nicotine advertising are banned in many countries. The World Health Organization recommends a complete tobacco advertising ban.
Tobacco harm reduction (THR) is a public health strategy to lower the health risks to individuals and wider society associated with using tobacco products. It is an example of the concept of harm reduction, a strategy for dealing with the use of drugs. Tobacco smoking is widely acknowledged as a leading cause of illness and death, and reducing smoking is vital to public health.
Tobacco politics refers to the politics surrounding the use and distribution of tobacco, likewise with regulations.
Smoking in China is prevalent, as the People's Republic of China is the world's largest consumer and producer of tobacco. As of 2022, there are around 300 million Chinese smokers, and 2.4 trillion cigarettes are sold there every year, 46% of the world total.
The use of tobacco products in Egypt is widespread. It is estimated that approximately twenty percent of the population uses tobacco products daily. Cigarettes are the most common form of tobacco consumption in Egypt, with an estimated twenty billion cigarettes smoked annually in the country. After cigarettes, shisha water-pipes are the most common form of tobacco consumption.
Smoking in Nigeria is prohibited in public places. It is punishable by a fine of not less than 50,000 nor exceeding 100,000.00 naira, or by imprisonment to a term of not less than 10 years or your lifetime, or by both a fine and imprisonment.
Smoking in Ecuador is more common among men and younger people. According to a study in 2004, 49.4% of men and 13.1% of women smoke. More than half of Ecuadorian smokers desire to quit. The Government of Ecuador plans to reduce second-hand smoke in public spaces by 2012. The tobacco industry in Ecuador includes the major players of Tabacalera Andina SA and British American Tobacco Ltd. Smoking is expected to decrease as the government enacts laws and the public becomes more aware of the dangers of smoking. Smoking is common in bars and dance clubs, but non-smoking signs in restaurants in Quito are generally respected.
Smoking in Iceland is banned in restaurants, cafés, bars and night clubs as of June 2007. A large majority of Icelanders approve of the ban. At the time the ban went into effect, almost one in four Icelandic people were smokers.
Plain tobacco packaging, also known as generic, neutral, standardised or homogeneous packaging, is packaging of tobacco products, typically cigarettes, without any branding, including only the brand name in a mandated size, font and place on the pack, in addition to the health warnings and any other legally mandated information such as toxic constituents and tax-paid stamps. The appearance of all tobacco packs is standardised, including the colour of the pack.
Smoking in South Korea has decreased overall for both men and women in the past decades. However, a high prevalence of tobacco use is still observed, especially with the rise of novel tobacco products such as e-cigarettes and heat-not-burn tobacco products. There are socioeconomic inequalities in smoking prevalence according to gender, income, education, and occupational class. Advocates call for measures to reduce the smoking rates and address smoking inequalities using a combination of monitoring and tobacco control policies. These measures include significant price hikes, mandatory warning photos on cigarette packs, advertising bans, financial incentives, medical help for quitting, and complete smoking bans in public places.
Smoking in Albania is prevalent as about 40% of Albanians smoke regularly. In Europe, only Turkey has a higher smoking rate than Albania. Albanians annually spend more than €300 million on tobacco products. Zog I of Albania was reported to smoke 200 cigarettes a day. Albania adopted tough anti-smoking laws in 2007, but they are not strictly enforced. Smoking prevalence is increasing, especially among females ages 13 to 15. The smoking rate for teens between the ages of 13 and 15 is currently 15%.
Smoking in Costa Rica is still somewhat prevalent, and according to the Global Adult Tobacco Survey (GATS) in 2015, 8.9% of the population smoked tobacco. The number of people exposed to secondhand smoke indoors while at the workplace was 6.3% while 4.9% were exposed in their own home.
Tobacco smoking in the Philippines affects a sizable minority of the population. According to the 2015 Global Adult Tobacco Survey (GATS) conducted under the auspices of the Philippines' Department of Health, Philippine Statistics Authority, the World Health Organization, and the United States Centers for Disease Control and Prevention, 23.8 percent of the adult population were "current tobacco smokers". This figures represented 16.6 million of 69 million adult Filipinos.
The scientific community in the United States and Europe are primarily concerned with the possible effect of electronic cigarette use on public health. There is concern among public health experts that e-cigarettes could renormalize smoking, weaken measures to control tobacco, and serve as a gateway for smoking among youth. The public health community is divided over whether to support e-cigarettes, because their safety and efficacy for quitting smoking is unclear. Many in the public health community acknowledge the potential for their quitting smoking and decreasing harm benefits, but there remains a concern over their long-term safety and potential for a new era of users to get addicted to nicotine and then tobacco. There is concern among tobacco control academics and advocates that prevalent universal vaping "will bring its own distinct but as yet unknown health risks in the same way tobacco smoking did, as a result of chronic exposure", among other things.
Tobacco smoking is popular in North Korea and culturally acceptable among men, but not for women. As of 2019, some 43.6% of men are reported to smoke daily, whilst in contrast only 4.5% of women smoke daily, with most of these being older women from rural areas. Smoking is a leading cause of death in North Korea, and as of 2021 mortality figures indicate that 14.2% of North Koreans die due to smoking-related causes, which is the 6th highest rate after China, Greenland, Kiribati, Denmark and Micronesia. There are tobacco control programs in North Korea, and although smoking was not prohibited in all public spaces, the smoking rates have declined since their peak in the 2000s.
Tobacco policy in Armenia is the attempt by the Armenian authorities to regulate smoking in Armenia. Tobacco laws and regulations are controlled by the Ministry of Health of Armenia. Armenian men tend to be the most common tobacco users, as 42.5% of men over the age of 15 smoke.
Smoking in Latvia is common, with a rate higher than the OECD average, and Latvian men are among the heaviest smokers in the European Union. One in four Latvians smoke, as compared to one in five in the rest of the European Union. While the overall smoking rate in Latvia has decreased in recent years, it is considered a significant factor in the country's significant health challenges, particularly with regard to preventable diseases such as heart disease, diabetes, and cancer.
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