What it would take to rid the world of smoking forever

The massive decline in smoking rates — from 42 percent in 1965 to 19 percent in 2012 — is America's biggest public health success of the past century.

Tobacco restrictions are estimated to have saved 8 million lives in the 50 years since the first surgeon general's report on smoking and health in 1964.

This is good — but not good enough, public health experts have begun to argue. The Centers for Disease Control and Prevention set a target of 2020 of getting the country's smoking rate below 12 percent. An editorial from researchers and public health officials in The Lancet this week called for "a world where over the next 25 years the sales of tobacco are phased out (although not prohibited), and in which fewer than 5 percent of adults use tobacco."

To achieve that goal, experts think we need to become more dedicated to policy implementation while also tackling the tobacco industry itself.

Smoking rates have both plummeted and spiked worldwide

The prevalence of smoking has fallen considerably in the US and other countries, so industry efforts are moving to where business is booming. (The Lancet)

The proportion of the total global population that smokes decreased 42 percent for women and 25 percent for men between 1980 and 2012. Four countries—Canada, Iceland, Mexico, and Norway—have reduced smoking by more than half in both genders since 1980.

Since 2005, tobacco use has been curbed by the Framework Convention on Tobacco Control, an international treaty that sets guidelines for tobacco sales and consumption. The treaty requires that countries adopt measures such as banning marketing, using detail warning on cigarette packaging, and protecting people from secondhand smoke in public places.

The World Health Organization treaty has been ratified by 180 countries. The US signed it but never ratified it, meaning we've acknowledged the importance of it but aren't technically bound by any of its provisions.

Countries that have ratified the FCTC are legally bound by these provisions, technically speaking. But implementation of the FCTC has been scattered and slow. Despite the change in prevalence, the number of smokers has grown significantly with population growth. In 1980, 720 million people smoked; in 2012, that number was almost 1 billion.

Smoking in the US is at a 50-year low

The CDC has an ambitious goal of getting smoking down to 12 percent in the next five years. (CDC)

Experts credit the numerous policy changes that have helped drive down the smoking rate over the past five decades. In 1965, the federal government began requiring cigarette packages to include warnings of the potential health risks. In 1988, it banned smoking on domestic flights shorter than two hours. By 2002, that ban had been expanded to include smoking on any US airline flight.

Many states have banned smoking in public places since Delaware passed the first such law in 2000. A 2012 study in Circulation found that when smoke-free laws were implemented in a city, there was an average decline of 15 percent in heart attack hospitalizations.

Another 2012 study in Archives of Internal Medicine looked at the impact of smoke-free laws in one Minnesota county over a decade. The study found a 33 percent drop in heart attacks per capita and a 17 percent decrease in the number of deaths from sudden cardiac arrest.

Obamacare makes experts even more hopeful that numbers will continue to fall, as cessation products to help people quit smoking are now covered under federal plans.

There's a growing customer base for tobacco

China has seen a huge boom thanks to aggressive industry marketing and a lack of tobacco control policies. (The Lancet)

As Americans continue to smoke less, citizens of other countries are smoking more — and cigarette sales are increasingly concentrated outside North America. Of the 667 billion cigarettes sold in 2014, 197 billion were sold in the Pacific region (stretching from Mongolia south to New Zealand), and 227 billion were sold in Europe, the Middle East, and Africa. In some countries — including Russia, Indonesia, and Armenia — a majority of men smoke daily. Smoking prevalence for women is above 25 percent in Austria, Chile, and France, and tops 30 percent in Greece. So while smoking seems to be decreasing in the US, there's still a huge customer base for tobacco — it's just shifting elsewhere.

Tobacco companies are suing poor countries over smoking regulations

Countries with a GDP much lower than a tobacco company's revenue have a hard time fighting litigation against tobacco regulation policies. (The Tobacco Atlas)

Tobacco industries are doing three things to contribute to growth of tobacco sales, experts say: marketing their products extensively, manipulating their prices, and lobbying against regulation.

The WHO estimates the tobacco industry spends tens of billions of dollars each year on advertising. Because tobacco sales and advertising are so heavily regulated in countries like the US and Britain, companies have flocked to countries where there's less regulation and more of an opportunity for a profit.

Particularly in low-income countries, tobacco industries also wield a huge amount of power thanks to their money. The corporations are able to use litigation to their advantage, targeting public health measures that hurt their industry. In poor countries, governments can't necessarily afford the defense against these types of lawsuits, says Anna Gilmore, a University of Bath researcher who authored one of the articles in The Lancet series.

Uruguay is one such case — the nation is in the middle of a legal battle over its graphic warning labels on cigarette packages. Tobacco giant Philip Morris International claims the labels go against a trade agreement between Uruguay and Switzerland (where PMI's corporate headquarters are located). Uruguay might not have been able to afford the current litigation, according to Gilmore, if not for the financial support of international NGO Bloomberg Philanthropies, which has stepped in to help. There are other examples of this, as well — big tobacco industries have a hold on many lower-income counties, and it's a huge problem public health experts are trying to figure out how to solve.

Strong regulations have been proven to dramatically decrease smoking rates

New Zealand is a great example of the impact of a full implementation of FCTC protocols. (Tobacco Control Data Repository)

By all accounts, it seems like many of the practices set forth by the FCTC should work: raising taxes on tobacco products, regulating interactions between lawmakers and the tobacco industry, implementing public protections from smoking, and so on. But the FCTC hasn't been put into action all that well.

"The implementation has been slow and underwhelming," says Paul Billings, senior vice president of advocacy and education at the American Lung Association. He's been working as an advocate for tobacco regulation since 1991, and two and a half decades of effort have shown him what works. To see progress, we have to see action, he says. The '90s saw a wave of legislation and efforts aimed at both changing tobacco policy and increasing public awareness. The combination is what helped to make a big dent, he says.

"There were smaller steps, but also important steps," he says, ranging from the EPA's report on the dangers of secondhand smoke to cities setting a minimum age for purchasing tobacco products. But in recent years, that momentum has dwindled.

We have to speed up the process, Billings says. None of the implementation, in the US or in other countries, has happened fast enough.

"The way to speed it up is by implementing the strategies we know work: raising the taxes, passing the comprehensive smoke-free air laws, regulating the product, providing cessation coverage, funding the comprehensive public education and counter-advertising programs," he says.

Just a handful of countries have been able to enact many of the FCTC protocols somewhat quickly, but they have seen great success in doing so.

New Zealand — which four years ago set a goal of becoming smoke-free in 2025 — provides one possible roadmap for necessary policies. Cigarette excise taxes have increased 10 percent each year, and legislation to standardize plain packaging for tobacco products to cut down on their appeal is currently being voted on. The work in New Zealand has significantly reduced smoking rates — 21 percent of adults smoked daily in New Zealand in 2006, and in 2013, that number was down to 15 percent.

Some countries actually own their own tobacco companies

The Chinese government is selling a massive number of cigarettes to its own citizens. (The Lancet)

A big problem for countries pledging to rein in tobacco use is that some of them are profiting from it. More than a dozen countries actually own tobacco companies, including Lebanon and China. And that's a huge contradiction, says Ali Mokdad, global health researcher at the University of Washington.

"A country cannot be saying to the world, 'I’m going to aggressively go against tobacco' and at the same time be making money on tobacco," he says. It's common sense, says Mokdad — if countries really want to curb use, they can't also sell tobacco on the side for a profit.

Even in places without such a noticeable tie between legislators and the industry, big tobacco still wields power. Experts think countries in which smoking is on the rise need to be able to swing back at the industry.

"The tobacco industry reigns among the most potent foes. They make a product that addicts people and kills them, but yet they manage to stay in business and make an enormous profit. They’re not to be underestimated," Billings says.

Gilmore knows there are bigger goals within the concept of a tobacco-free world — like workplaces and pharmacies playing a role in decreasing tobacco use — but those won't be feasible until the tobacco industry itself is reined in, she says.

But is the goal — that seemingly far-off 5 percent — reachable by 2040?

"Feasible? Yes. But I’m an optimist," Billings says.

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