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historical perspectiv e
The Global Smoking Epidemic:
A History and Status Report
Robert N. Proctor
Abstract
The World Health Organization estimates that tobacco causes approximately 5 million deaths annually worldwide, a number expected to double by 2025. Cigarette consumption grew from only a few billion per year in
1900 to present values of approximately 5.5 trillion worldwide. Historical causes for the rise of smoking include
the invention of flue curing, safety matches, and cigarette rolling machines, but also the distribution of cigarettes to soldiers during World War I, mass marketing, the failure of governments to limit consumption, and the
duplicitous denial of hazards by manufacturers. Cancers of the lip, throat, and tongue were linked to tobacco
as early as the 18th century, but a lung cancer hazard from smoking was not suspected until the first decade
of the 20th century. Epidemiologic evidence began to emerge in the 1920s, and by the 1950s, the causal link
with cigarette smoking was well established. Epidemiologic studies, animal experiments, and studies demonstrating pathologic changes in lung tissues at autopsy were 3 pivotal sources of evidence. However, the tobacco industry refused to concede the reality of tobacco hazards until the late 1990s. Instead, the industry
sought to target physicians and others with its message of “no proof,” using subtle techniques of deception,
including the funding of spurious research, duplicitous press releases, propaganda efforts directed at physicians, and the employment of historians to construct exculpatory narratives. The World Health Organization’s
Framework Convention on Tobacco Control promises to standardize global tobacco control measures, including policies to limit smuggling. Effective means of reducing tobacco use include counter-advertising, increased
taxation, smoke-free workplace legislation, and litigation against the industry.
Clinical Lung Cancer, Vol. 5, No. 6, 371-376, 2004
Key words: Cigarettes, Lung cancer, Tobacco
Big Numbers
ple. It is one of the world’s leading agricultural products. In the
United States alone, approximately 26 million pounds of pesticides are applied to tobacco each year.3 Tobacco is a major cause of
deforestation, partly as a consequence of ground-clearing to plant,
but also because of how tobacco leaves are cured, usually by heating and drying in sheds or barns, using wood for fuel. Current estimates are that for curing alone (not counting clearing for cultivation), 200,000 hectares of forest are cut down every year.4 That
is approximately 2% of the world’s annual deforestation.
Every year, thousands of people are killed by fires caused by cigarettes, approximately 1,000 in the United States alone according
to the National Fire Protection Association, which also estimates
approximately $400 million in property damages in the United
States. The far greater hazard, though, comes from inhalation of
poisons. Each cigarette brings approximately 10 mg of soot, tar, ash,
phenols, benzpyrene, hydrogen cyanide, formaldehyde, and radioactive polonium 210 into the lungs of smokers. Assuming 10
Approximately 5.5 trillion cigarettes are smoked annually. With
6 billion people on Earth, this means a global consumption rate of
approximately 900 per person per year.1,2 If all the cigarettes
smoked every year in the world were placed end to end, they could
circle the globe 12,000 times or stretch from the earth to the sun
and back with enough left over for a few side trips to Mars.
We often think about tobacco as something that is smoked, but
we should not forget that it also has to be planted, grown, harvested, cured, chopped, blended, rolled, sold, advertised, and increasingly defended in court against claims that it has killed peoDepartment of History, Stanford University, CA
Submitted: Jan 26, 2004; Revised: Mar 8, 2004; Accepted: Mar 9, 2004
Address for correspondence: Robert N. Proctor, PhD, Department
of History, Building 200, Stanford University, Stanford, CA 94305
Fax: 814-863-7840; e-mail: [email protected]
Electronic forwarding or copying is a violation of US and International Copyright Laws.
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by Cancer Information Group,
ISSN #1525-7304, provided the appropriate fee is paid directly to Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923 USA 978-750-8400.
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The Global Smoking Epidemic: A History and Status Report
mg of soot, tar, and nicotine per cigarette, the quantity of cigarettes
smoked worldwide is such that approximately 55 million kilograms
are inhaled directly into the lungs of smokers every year. That is
enough to fill 5000 railroad boxcars with 10,000 kilos per car.
Disease Effects
It is relatively easy to calculate disease effects caused by cigarettes because they are homogeneous and highly regulated, primarily for taxation purposes. This means we have excellent consumption records, perhaps better than for any other consumer
product. The dose response is also more or less linear, which
means that disease impacts are not difficult to calculate.
According to the World Health Organization5 and other authorities,6 5 million annual premature deaths in the world can now
be attributed to tobacco, a number we can expect to grow as recent
decades of growth in cigarette consumption take their toll. (There
is typically a lag time, or latency, of approximately 25 years between
exposure and cancer expressions.) Poor and rich are nearly equally
affected, but there is still a significant asymmetry between the sexes:
nearly 4 times as many men die from tobacco addiction as women,
although that gap is closing. We always hear about cancer, but tobacco-induced heart disease has historically claimed a larger number of lives, now approximately 2 million people per year, followed
by chronic obstructive pulmonary disease and lung cancer with approximately 1 million deaths each.6 These numbers will increase
over the next few decades even if everyone were to stop smoking
today. If smoking rates remain constant at present levels, however,
we can expect a peak of approximately 10 million deaths per year
from cigarettes in the next 20-30 years, with a total for our present
century on the order of 1 billion deaths.7,8 Given that there have
been only approximately 60 billion people on the planet since the
evolution of Homo sapiens circa 200,000 years ago (Kenneth Weiss,
PhD, personal communication, July 2003), and figuring another
20 billion for the 21st Century, this means that, by the year 2100,
more than 1% of everyone who has ever lived on the planet will
have died from tobacco. Approximately one third of those deaths
will be from lung cancer—approximately 300 million.
Numbers such as these can be numbing; it is difficult to grasp
their significance. We measure them because we can, perhaps because we make our careers from such measurements or from interventions we hope will reduce them. The disappointment, of
course, is that there are often things we know a lot about but still
cannot do much to control. It is frustrating to see friends or patients or students or even strangers continuing to smoke when it is
so obviously the cause of diseases that are so easy to prevent. Smoking is the major cause of lung cancer, but it is also a leading cause
of heart attacks, chronic obstructive lung disease, emphysema,
cancers of the lip, tongue, larynx, and pharynx, and a menagerie of
other maladies, including bladder cancer and blindness.
How did we come into such a world, which London’s Royal
College of Physicians more than 30 years ago characterized as
“the present holocaust”?9
The Rise of the Cigarette
Tobacco was cherished by the Mayans and other Native
Americans long before Christopher Columbus brought back
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nicotiana seeds and leaves from the New World to Europe. Tobacco was smoked, chewed, or “drunk” in many different forms
for hundreds of years with only limited health effects. The turning point from the perspective of world lung history does not
come until the 19th century, however, when a series of social
and technologic changes allowed “the golden leaf ” to become
far more popular and far more injurious. We can identify 6 principal stages in the rise of the modern cigarette:
First was the invention of flue curing,10 a fermentation process
chanced upon in the 1830s in the Piedmont region of North Carolina, allowing the production of a bright yellow tobacco leaf that,
when smoked, could be drawn deeply into the lungs without
coughing. Flue curing (heating by means of very hot air circulating through a flue or vent) increased the sugar content of the leaf,
making it less harsh when smoked. The elevated temperature
transforms the nicotine into a salt, allowing it to be dissolved in an
aerosol form and delivered to the lungs with less of an alkali
“sting.” It is hard to overestimate the impact of this innovation:
flue-curing made it possible for the first time to inhale tobacco
smoke comfortably, producing a more profound level of addiction.
(In comparison, smoke from pipes and cigars was normally not inhaled, and the health impacts were consequently much less dire.)
A second, less obvious, change was the invention of safety
matches. It is hard to imagine today, but it was not such an easy
thing to light any kind of fire before the 19th Century. You needed either a preexisting flame or flint and steel (or pyrites) plus
some kind of tinderbox (containing, for example, singed cotton
or powder from certain fungi) if you did not want to rub 2 sticks
together or wait around for lightning. White phosphorus matches were invented in the 1830s, but these were dangerous, catching fire sometimes when (and where) you did not want them to;
the fumes were also quite poisonous, causing a septic rotting of
the teeth known as “phossy jaw.”11 Safety matches were patented in 1855 by Johan Lundstrom of Sweden and matchbooks
were introduced shortly thereafter, making it possible to smoke
habitually, ubiquitously, and with convenience.
A third innovation in the 1880s was the development of the
Bonsack rolling machine, which could crank out 100,000 cigarettes per day, a production rate 500 times faster than that of
traditional handrollers. Today’s machines are even faster, of
course, producing about 273 cigarettes per second, which is why
the Philip Morris manufacturing facility in Richmond, VA, is
able to produce 730 million cigarettes per day. Decreasing costs
of production allowed mechanically produced cigarettes gradually to replace cigars and pipes as the favored mode of smoking,
especially when advertised as a more mobile, “on-the-go” form
of smoking. This occurs at a time when other consumer goods
were being prepackaged and standardized for rapid insertion
and delivery, including candy bars, lipstick, and even bullets.
Cigarettes were popularized about the same time as ammunition
cartridges, speeding the efficiency of killing in both cases.
An important turning point was the first World War, during
which cigarettes were handed out to soldiers as part of rations.
Cigarettes were widely believed to relax the mind and calm the
spirit, gaining a reputation with the help of clever advertising
men as “friends in the trenches.” The Red Cross handed out cig-
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Robert N. Proctor
arettes, and doughboys returning from Europe helped spread
the habit in the Americas. Cigarettes had actually been banned
in many US states in the decades leading up to the war, but with
the increasing suspicion of Prohibition, these laws were repealed
(the last in 1927) and smoking rates skyrocketed. The tobacco
industry had already shown its political clout by having tobacco
excluded from governance by the Pure Food and Drugs Act of
1906 (establishing the US Food and Drug Administration
[FDA]). The industry fought hard in Congress for this exclusion,
winning a separate and weaker governance by the Treasury Department in a new Bureau of Alcohol, Tobacco, and Firearms.12
Clever marshalling of political influence had earlier led to tobacco’s removal from the official catalog of US Pharmacopeia, a redefinition engineered by American Tobacco’s “Buck” Duke to
ward off governance by the FDA.13
Another factor in the triumph of the cigarette was the growth of
mass consumer marketing. Cigarettes would eventually become the
most widely advertised American consumer product, with billions
of pages of ads in newspapers and popular magazines, millions of
square feet of billboard space, and countless hours of ads in movie
theaters. In 1922, Lucky Strike cigarettes became the first product
ever advertised by skywriting. Radio and television would later be
heavily targeted, with doctors, sports heroes, and movie stars being
paid to plug tobacco. Americans 40 years of age or older will remember what “LSMFT” stands for (“Lucky Strike Means Fine
Tobacco”), and how far you’d walk for a Camel. Many popular television shows in the 1950s and 1960s were brought to you by
Marlboro, Winston, Lucky Strike, etc, including favorites such as
“I Love Lucy,” “The Flintstones,” and “The Beverly Hillbillies,” all
of which incorporated ads for cigarettes. The Federal Trade Commission’s rulings allowed cigarettes to be advertised on television,
but only on shows where no more than 45% of the audience was
expected to be underage. Manufacturers worked with producers to
keep the “youth appeal” of such shows at the pivotal 45% to keep
as many children watching as possible. Movie stars were also paid
to smoke or to flash a particular brand on film. Sylvester Stallone,
for example, was paid half a million dollars to smoke Lucky Strikes
in 5 of his “Rocky” and “Rambo” movies.”14
One of the most important factors behind the rise of the cigarette was its recognition by governments as a reliable source of tax revenue. Cigarettes are easily taxed for some of the same reasons they
are easily smoked: they are compact, homogeneous, easy to store,
easy to count, and always in demand in consequence of addiction.
Governments seeking to enrich their treasuries recognized these
virtues, establishing state-owned tobacco monopolies to centralize
and standardize production for purposes of extracting revenue. By
the 1930s, one twelfth of Germany’s entire national tax income was
coming from tobacco taxes. The Nazi brownshirts (Sturmabteilung)
financed more than half of their activities from their own brand of
Sturmzigarette, and other political parties had their own brands.15
In the United States, federal tobacco taxes in 1929 were $450 million,10 but as early as the 1880s, tobacco taxes constituted nearly
one third of all tax revenues paid to the federal government.16
Even today, cigarettes constitute a major source of revenue for
most modern states. Japan gets approximately 2% of its total national revenue from cigarettes; China gets almost 10%, Greece
gets 8%, and Brazil 5%.17 This produces a kind of codependence,
or “double addiction:” health officials often want to curtail tobacco use, but governments find it profitable to keep it going.
State ownership of tobacco business has also meant that treasury
officials are often at odds with health officials on how best to control tobacco, or whether it should be controlled at all.
This is a problem in Japan, for example, where the government is the leading tobacco manufacturer; the same is true in
China, where government-owned factories produce approximately one third of the world’s cigarettes. A conflict of interest
is set up between health and tax officials, which is one reason so
little has been done to curb tobacco use. Short-sighted economic considerations often trump what is best for people’s health.
The Discovery of Tobacco Hazards
Recent lawsuits against the tobacco industry have charged it
with marketing a faulty product, conspiring to defraud the
American public, failing to warn of potential hazards, and a
number of other torts.18 Central in many of these trials has been
the question of whether the industry acted responsibly in denying evidence of hazards. The counsel of expert historians has
been sought to determine when it was first possible to have
known that cigarettes could cause injury and death, and the
question has often been boiled down to 2 separate queries: (1)
whether ordinary people at some particular point in time were already aware of the risks and therefore have only themselves to
blame for smoking; and (2) whether the “state of the art” of medicine was such that, after some particular point in time (usually
the mid-1950s), the industry should have known and admitted
that cigarettes were dangerous. This second question—when the
tobacco hazard was discovered—is of sufficient interest that we
should take a moment to review a bit of the history.
It would be wrong, of course, to imagine that there is only
one tobacco hazard; there are many. Pipe smoking was linked to
cancer of the lip in the 18th Century and to cancer of the
mouth and throat in the 19th Century.15 Cigarette smoking was
rare until the 1880s and 1890s, however, which is why it took
some time for the lung cancer hazard to be discovered.
Lung cancer was first linked to tobacco in the 1890s, when a German physician by the name of Hermann Rottmann noticed that
women working in tobacco factories were more likely to get lung
cancer. He was right in his observation but wrong in his explanation,
believing it was not smoking per se but rather the inhalation of tobacco dust that was causing the malady.19 Today we would realize
that these tobacco workers simply had easy access to cigarettes and
were often smokers, leading to their higher disease rates.
Lung cancer was still very rare in the early decades of the 20th
Century, however—so rare that physicians writing on the topic
would apologize for dwelling on such a trivial malady (as Isaac
Adler does in his famous 1912 Primary Malignant Growths of the
Lungs and Bronchi).20 Only a few hundred cases were known in the
published literature by this time, and even though many more must
have been misdiagnosed as phthisis or tuberculosis or consumption,
the disease can not have been very common. Lung cancer was not
even identified as a distinct malady until the first part of the 19th
Century,21 and when cancer registries began to be established in
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Germany toward the end of that century, accompanied by statemandated autopsies, lung cancers were rarely encountered.
Early in the 20th Century, however, lung cancers began showing up more often, both clinically and at autopsy, prompting head
scratching and, eventually, alarm. At the annual meeting of the
German Society for Pathology in Göttingen in 1923, some of Germany’s leading medical scholars debated various possible causes for
the epidemic, including air pollution, increased exposure to Xrays, asphalt dust, and tar emissions from newly paved roads, the
growing popularity of cigarettes, exposure to chemical warfare
agents in the Great Patriotic War, and even racial intermarriage.22
Shortly thereafter, Fritz Lickint in Germany23 and Lombard and
Doering in the United States24 produced statistical studies showing that patients with lung cancer were very often smokers. More
sophisticated techniques were developed in the 1930s and 1940s,
including the methods of case-control epidemiology, whereby
smoking rates among patients with lung cancer are compared
against those of a carefully-selected control population—people
with other cancers, for example, matched for age, occupation, sex,
and so forth.25,26 In the 1950s, these were joined by new and more
powerful epidemiologic studies, including studies with much larger cases and controls and quantified estimates of the probability of
error (such as χ2 analysis).27,28 Prospective, or cohort, studies29-31
reaffirmed the link, as did “mouse painting” experiments (showing
that tobacco tars could cause tumors when smeared onto the
shaved backs of mice)32 and studies of cellular pathology (at autopsy) showing that precancerous changes in lung tissues were directly associated with exposure to tobacco smoke in humans.33 By
the mid-1950s, there were 3 strong and distinct sources of evidence indicating a lung cancer hazard: epidemiologic studies (both
prospective and retrospective), animal experiments showing that
tobacco tars could cause epithelial malignancies, and pathologic
evidence showing a clear association between cellular pathology
and levels of individual tobacco use. Hilding et al had also shown
that smoking produces ciliastasis and tar accumulations in precisely those parts of the lungs most likely to develop cancers.34
The Industry’s Response
The difficulty is that for more than 40 years, all these forms of
evidence were vigorously denied by the tobacco industry. Epidemiology was ridiculed as mere statistics, animal experiments,
and pathology was mere anecdote and subjective supposition. By
the late 1950s, the tobacco industry had developed an elaborate
strategy by which each new proof of a hazard would be met by insinuations of doubt and calls for endlessly more research.
The industry used many different methods to deny tobacco
hazards or to avoid having to admit them. Some of the more
forceful and effective methods were in the following:
Distraction and Decoy Research
The Industry’s “Frank Statement” of January 4, 1954, published
in 448 American newspapers, announced the establishment of a
Tobacco Industry Research Committee (TIRC), later renamed the
Council for Tobacco Research (CTR), the proclaimed purpose of
which was to support research into “all phases of tobacco use and
health.”35 The Council never supported research that could impli-
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cate tobacco in any health hazards, however; the goal was simply
to give the impression the industry was serious about the health
danger, when in fact it was doing little or nothing about it. The
TIRC sponsored what can be called “reassurance research” on topics generally unrelated to the question of whether and to what extent tobacco was causing death or illness. British tobacco authorities recognized this when they visited the United States in 1958,
complaining that the TIRC was supporting “almost without exception projects which are not directly related to smoking and lung
cancer.”36 Four decades later, New York Attorney General Dennis
C. Vacco was harsher when he ordered the disbanding of both the
CTR and the Tobacco Institute, characterizing these as “fronts”
serving as “propaganda arms of the industry.”37
Suppression of Internal Industry Research
In September 1953, the American Tobacco Company sponsored a series of experiments to see if the “mouse painting” studies of Wynder et al33 could be replicated using methods more
closely approximating those of actual smoking. At the laboratories of one of its major suppliers, the Ecusta Cigarette Paper
Company in Pisgah Forest, NC, whole fresh smoke was continuously blown onto the skin of shaved mice in a series of experiments conducted with the assistance of Paul S. Larson and Harvey B. Haag from the Medical College of Virginia. The results
were clear: in 6 of the 8 mice exposed, “biological activity” (ie,
precancerous cellular changes) was reported.38 American Tobacco Company president Paul Hahn was notified of the results,
but the experiment was never made public, and would not be
known even today without the release of internal industry documents in consequence of litigation. The experiment is particularly significant in that Hahn was notified of the results shortly
before letters were sent to the heads of Philip Morris, Reynolds,
and the other American tobacco companies inviting them to
New York’s Plaza Hotel to plan a coordinated strategy to deal
with growing evidence of cancer hazards. That meeting culminated in the drafting of the “Frank Statement” and represented
the beginning of the conspiracy to dismiss evidence of hazards.35 The coincidence suggests that the conspiracy was
launched at least partly in response to the industry’s confirmation of the cancer threat in its own laboratories.
Efforts to Influence Doctors Through Propaganda
The industry published a number of pamphlets and brochures
on what it liked to call the cigarette “controversy,” the point of
which was usually to argue that there was insufficient evidence to
implicate cigarettes as a cause of cancer or any other malady.39 Millions of copies of such pamphlets were sent to doctors, politicians,
journalists, editors, and other influential medical and media figures.
Popular science and medical magazines were also established to bolster the industry. In 1962, for example, Lorillard established the Scientific Fortnightly to advertise Kent’s micronite (asbestos) filter;
high-quality articles on space exploration, archaeology, and subatomic physics were sandwiched between prominent ads for Kent,
which invariably graced the front and back of the magazine. A more
direct campaign was initiated with the founding in 1958 of Tobacco and Health Research, a newsletter published by the Tobacco In-
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stitute to draw attention to “doubts about the smoking theory.”40
Non-tobacco causes of lung cancer were a major focus, with articles
exploring genetic predispositions, infections of various sorts, atmospheric pollution, occupational exposures, misdiagnoses, and
metastases from other parts of the body—even one’s date of birth;
anything but tobacco. Titles of typical articles from the mid-1960s
include “Rare Fungus Infection Mimics Lung Cancer,” “English
Surgeon Links Urbanization to Lung Cancer,” “Nicotine Effect is
Like Exercise,” “Lung Cancer Rare in Bald Men,” “28 Reasons for
Doubting Cigarette-Cancer Link,” and “March Birth, Lung Cancer Linked.” Tobacco and Health Research was mailed free of charge
to 340,000 American doctors, scientists, dentists, and medical
school faculty, with tens of thousands of additional copies going to
“communications media, selected opinion leaders, brokers and analysts, members of tobacco farm groups, tobacco industry suppliers
and others with an interest in the industry.”41
Use of Code Names Inside the Industry
The term “Zephyr” was sometimes used instead of “lung cancer,” for example, and “cancer” was often called “biological activity” or “pseudo-epitheliomatous hyperplasia.” Nicotine was similarly disguised as “W,” and benzpyrene had the cover-name
“Borstal.” Industry documents from the 1950s talk about the
Journal of Zephyr Research42 and the like, although secrecy continued into more recent decades. Industry research scientists have
testified that “[t]hey didn’t want us to call anything cancer.”43
Distribution of Deceptive Articles in Popular Magazines
In January 1968, for example, a sportswriter by the name of
Stanley Frank published an article in True magazine (circulation
2 million) stating that there was “absolutely no proof that smoking causes human cancer.”44 The Wall Street Journal later reported that copies of the article had been sent out to 185,000 doctors, 41,000 life scientists, 19,000 educators, 10,000 government officials, and hundreds of thousands of other opinion
makers, all at the expense of the Tobacco Institute and its associates. Those who received the article were not told that its author had been paid for his services by the industry or that the
entire project was an industry invention.45 The article was later
shortened for publication in The National Enquirer, where approximately an additional 1 million readers encountered it
under the new title, “Cigarette Cancer Link is Bunk.”
Hiring of Experts to Defend the Industry in Court
Thousands of doctors, scientists, and humanists have performed such services for the industry, earning fees as high as
$1500 per hour for testifying.46 Preparation of experts for possible use in litigation was a major goal of the “Special Projects”
run by the Council for Tobacco Research,14 but other means
have been used. From 1987 to 1993, for example, Philip Morris organized a secret “Project Cosmic” to create “an international network of scientists and historians” to write sympathetic histories that would cast the industry in a favorable light.47
Many of these strategies were franchised into other countries in
the 1970s and 1980s, as industry-financed “tobacco institutes”
sprang up in places like Australia, New Zealand, and Japan, the
purpose in each case being to dispute evidence of health effects.
Globalization of the Antitobacco Movement
There are lots of different ways that smoking can be and has
been curtailed. Nineteenth and early 20th Century bans on cigarettes periodically reduced tobacco use, although the repeal or
lapse of such bans in the 1920s, combined with mass marketing,
allowed demand to spring back. Recent efforts to limit the space
where you can smoke have had an impact. Tobacco has been
banned in many public spaces, and at least 6 US states and many
local communities have declared themselves “smoke free,” meaning uniform bans in restaurants, bars, and public buildings.48
Direct counter-advertising has also proven effective, most famously in the early 1970s when antitobacco groups successfully demanded “equal time” to air television ads featuring smokers dying from lung cancer. The industry quickly realized how
effective these ads were, and chose to stop all of their own advertising in order to have these negative ads cease. The United
States still has relatively weak warning labels on cigarette packaging, but many governments now require graphic and disgusting images on cigarettes—of diseased lungs or stained teeth, for
example—which hit much harder than pure text warnings.
Taxation has become another effective method of tobacco
control. In New York City, a single pack of 20 cigarettes can cost
up to $7.50 after federal, state, and local taxes. France has recently raised its price per pack from 4 to 8 Euros, and other nations are following suit. Taxation is effective because people
smoke less when it costs them an arm and a leg. This is a regressive tax, as the poor smoke more than the rich, but smoking itself is regressive from the point of view of cost and health effects.
One unfortunate consequence of taxation has been the growth
of smuggling. Cigarettes are not very expensive to produce: in the
United States, with modern manufacturing methods, cigarettes
could theoretically be cranked out and sold at a profit for only 40
or 50 cents per pack. If cigarettes can be produced for less than one
tenth of their price on the street, however, this means there are
enormous incentives to cheat the system. All you have to do is buy
where they are cheap and sell where they are expensive. There are
several notorious instances of this, including cases in which the
manufacturers themselves were found to have collaborated with
smugglers while simultaneously using the threat of “law and order”
to call for a rollback of tobacco taxes. Canada’s was the most infamous case, in which the industry encouraged smuggling across
Native American reservation borders,49 but the industry has also
been implicated in money laundering schemes for the Colombian
cocaine cartel.50 The World Health Organization estimates that as
many as 25% of all cigarettes sold in the world are smuggled.
Smuggling is one reason efforts have been made to establish a
global tobacco treaty, the idea being that effective controls are
going to require international coordination. A recent cause for
celebration in this realm has been the Framework Convention on
Tobacco Control (FCTC), signed by 192 countries in May 2003
and now under review for final ratification by individual nations.
The agreement requires ratifying nations to implement the printing of health warnings that cover one third of the package of cigarettes, protections for nonsmokers in public places, bans on ad-
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vertising within 5 years of ratifying, steps to eliminate smuggling,
and other measures.51 The treaty is modeled on global environmental treaties, notably the 1992 Framework Convention on
Climate Change. The idea in both instances is that some problems cannot be solved by separate nations going it alone. The
FCTC is important as the world’s first public health treaty, although it remains to be seen if it will have any teeth.
Tobacco litigation has provided yet another avenue for public
health promotion in the United States, though most nations do
not have the legal traditions to follow down this path. A major
blow to the industry came in 1997 with the Master Settlement
Agreement with US state attorneys general, which required the
tobacco companies to pay $350 billion to US state treasuries over
a period of 25 years.52 The ongoing federal case may exact an even
higher toll, although it remains to be seen what kind of impact
this will have on cigarette consumption. The strategy of the industry has been to transfer whatever costs it can onto consumers
while focusing marketing efforts onto those parts of the world
where smoking is not yet epidemic. People of lower socioeconomic status have long been major targets of the industry, which
helps explain why smoking has become very much a class phenomenon. A 1994 study found that 3% of all American doctors
smoke, compared with 18% of all registered nurses and 27% of
all licensed practical nurses.53 International cooperation will be
crucial if we are to avoid a situation in which the richer parts of
the world stop smoking while developing nations become addicted. The situation is different in different parts of the world, however. In Greece, for example, according to a 2003 study by the
Hellenic Cancer Society, nearly one third of all physicians still
smoke, which indicates a legacy of feeble health activism. Among
these smoking doctors, 39% smoke in front of their patients.54
A Political Disease?
Globally, according to the World Health Organization, approximately 10 million people are diagnosed with cancer every year, approximately 1.2 million of whom have lung cancer. Lung cancer
has become the most common cause of cancer death worldwide,
killing approximately 1.1 million people every year,55 which
means that mortality rates are still depressingly close to morbidity
rates. The fact that such an easily preventable disease still remains
the world’s largest killer among cancers, with many more deaths to
come in the future, reminds us how important it is to address cancer not just in the clinic or the hospital, but in governments at all
levels in the popular imagination. Cancer remains a political disease in need of creative political solutions.
References
1. USDA, United Nations. World Cigarette Consumption per Person, 1960-2002. Available at:
http://www.earth-policy.org/Updates/Update34_data.htm#CigWorld. Accessed July 1, 2003.
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