The tobacco epidemic spreads / by Judith Mackay

The tobacco epidemic spreads Tobacco kills approximately two and a half million people each year throughout the world. It is the largest single, pre- ventable cause of death in the world today, responsible for many cancers, coronary heart disease, pe- ripheral vascular disease, chronic bronchitis and emphysema. Taken in whatever form; it is a dangerous, expensive and addictive habit. Contrary to popular opinion, the greatest excess mortality from to- bacco is not in old age, but in pro- ductive middle life. One quarter of smokers die prematurely from the habit. This appalling statistic places tobacco in a unique risk category, W oRLD HEALTH, October 1988 by Judith Mackay Or Judith Mackay is Execu- tive Director of the Hong Kong Council on Smoking and Health and a Member of WHO's Expert Advisory Panel on Tobaccp or Health'. '<,, far ahead of the risks of other con- sumer goods such as alcohol, sugar, cars or motor bikes. Another dis- tinction is that many of these other consumer goods are dangerous when abused or misused, such as drinking and driving together, or driving too fast , whereas tobacco is simply dangerous when used as in- tended by the manufacturer. The dangers of tobacco have long been accepted by all competent sci- entists, and today the only chal- lenge to this medical consensus comes from the tobacco industry. Indeed, this refusal to admit can- didly that health dangers result from smoking may be cited as proof of the tobacco industry's lack of credibility on all topics. The major concern about tobacco use in the world today is the in- crease in developing countries. While tobacco markets are decreas- ing in the west at the rate of one per cent per annum, smoking is in- creasing in developing countries at an average of two per cent per 9 annum. In other words, for every smoker who quits in the United States or Europe, two people start smoking in a developing country. WHO's World Health Statistics An- nual, 1986, commented that the number of cigarettes smoked out- stripped population growth in all developing regions. A WHO group of experts commented : "Whereas in most industrialised countries the smoking habit is decreasing and be- coming socially less acceptable, in developing countries it is on the in- crease, fuelled mainly by intensive and ruthless promotional cam- paigns on the part of the trans- national tobacco companies. Unfor- tunately, in most developing countries the legislative controls and other measures-which in in- dustrialised countries succeed in limiting the use of tobacco-do not exist or are at best inadequate. " The experts predicted that smok- 10 ing diseases "will appear in devel- oping countries before communi- cable diseases and malnutrition have been controlled, and thus the gap between rich and poor countries will widen further. " wHo has estimated that more than 50 per cent of men but only five The tobacco epidemic spreads Left: A Hong Kong poster conveys the Chi- nese-language message-in cigarettes. Below: Even the buses in Singapore become travelling posters warning against tobacco abuse. Photo WHOrr. Farkas Right: Tobacco use is still increasing in some countries. Curbing smoking is an im- portant strategy for preventing cancer. Below right: A New Zealand poster recalls a painting made by Van Gogh some 80 years ago. per cent of women smoke in devel- oping countries compared to about 30 per cent of both sexes in the in- dustrialised world. So the challenge in the Third World is to maintain these low smoking rates among women while reducing the high smoking rates among men. Developing countries can ill af- ford the costs of smoking. Tobacco consumption is costly to the indi- vidual smoker whatever the total family income, especially in devel- oping countries . Money that could be used to buy food for the whole family is diverted to a product with no nutritional value whatsoever. Disability or death of a productive breadwinner will have serious re- sults for the rest of the family in a poor country. But tobacco is also costly to governments. In the view of the Food and Agriculture Organization (FAO) : "Tobacco growing is likely · to be deleterious in terms of both public health and long-term nation- al economic interest." Dr Roberto Masironi, the coordi- nator of the WHO Programme on Tobacco or Health, says bluntly: "Tobacco economics is sham eco- nomics." This is because the price W oRLD HEALTH, O ct ober 1988 The tobacco epidemic spreads Operating on a mouth cancer in India . Photo WHO/E. Schwab that countries have to pay for to- bacco use usually far outweighs the "benefits" of tax collected. The costs include medical and health costs ; the expense of lost produc- tivity; social welfare costs resulting from premature death and disabil- ity; fire losses ; the lost use of land that could have been used to grow nutritious food. In Asia particularly, most of the profits from the sale of tobacco by the transnational tobacco compa- nies benefits neither the countries nor the people. Instead, the profits... are returned to the boardrooms and shareholders of the "Western" world. In Beijing recently, a senior health official likened this to "a new opium war. " Certainly for both health and economic reasons, reducing tobacco use is crucial for developing countries. Nowhere is the tobacco battle being fought more vigorously than in Asia. One only has to read the recent headlines in World Tobacco, the industry's journaL-" Bright fu- ture predicted for Asia Pacific " witb the sub-headings "Growth po- tential" and "More smokers" with emphasis on the potential Chinese market-to view with alarm the penetration of the foreign. tobacco companies into Asia. In the same edition, the tobacco industry confi- 12 dently predicted: "The most con- servative estimation is that sales in Asia will increase by 18 per cent by the year 2000." The "Western" tobacco industry operates with a different standard in developing countries. For exam- ple, cigarettes are sold in many countries in Asia without health warnings that would be compulsory in their country of origin. In addi- tion, the tar content of cigarettes sold in Asia is higher than in indus- trialised countries. A recent analy- sis conducted by the American Health Foundation reported that American cigarettes sold in the Philippines yielded significantly higher values of tar, nicotine and carbon monoxide than exactly the same brands sold in the United States. And promotional campaigns have especially targeted women. The tobacco companies wield considerable political influence. Trade sanctions or the threat of such sanctions have been made against Hong Kong, Taiwan, Japan and Korea unless they open their markets to the sale and advertising of American tobacco products. For an industry that speaks so frequent- ly of freedom, the use of this kind of political coercion is noteworthy. Is it already too late to heed the warning? The epidemic of tobacco- related diseases, deaths and disabil- ity does not lie in the future in Asia; it has already begun. No longer are the communicable dis- eases the major cause of death. At a WHO Western Pacific Regional meeting on Tobacco or Health, held in Tokyo last November, it was em- phasised that the two most com- mon causes of death in Asia are now cardiovascular disease and cancer, both of them tobacco- related. Yet many countries in Asia, more accustomed to dealing with com- municable diseases, are not familiar with this new type of epidemic. Many also lack the legislative re- straints and other programmes nec- essary to tackle such an epidemic. Is it possible to be optimistic about smoking in Asia? At first sight, it may appear difficult to be so. Certainly disease, disability and death will increase over the next few decades. The activities of the tobacco industry afford few grounds for comfort. But, health data are slowly being collated in Asia. This is a crucial first step in explaining to doctors, govern- ments, the media and the public just how bad the tobacco epidemic is and will become. For example, there has been widespread concern at the prediction of Oxford epide- miologist Richard Peto that, of all the children alive today in China under 20 years of age, 50 million will die prematurely from tobacco use. Another encouraging factor is the emergence in Asia of national anti-smoking bodies, chest and can- cer societies and consumer groups, all of them dedicated to tobacco control and non-smokers' rights. And there is growing support from governments. Remarkably similar battles are being fought not just in Asia but all over the world. The tobacco indus- try is now organized globally to fight anti-smoking measures. Any country attempting to pass effec- tive legislation, for example, can expect an intense and bitter con- frontation with the tobacco indus- try. So there is a crucial need to share international expertise in countering the tobacco industry at political and legislative levels. This, too, has begun in Asia. There is a well-known ancient Chinese saying that "A journey of 10,000 miles begins with a single step." Very probably that first step towards containing the tobacco epidemic has already been taken in Asia. • WoRLD HEALTH, October 1988