Journal of Public Health Medicine
Vol. 23, No. 2, pp. 91–97
Printed in Great Britain
For debate
Lessons from tobacco control for advocates of
healthy transport
Jennifer Mindell
Summary
Many parallels can be drawn between cigarettes and motor
vehicles, smoking and car driving, and the tobacco and the
auto/oil industries. Those promoting healthy and sustainable
transport policies can learn lessons from tobacco control
activities over the past 50 years. Evidence-based legislation
is more effective than negotiated voluntary agreements
between industry and government. Media advocacy is
crucial to reframe the issues to allow changes in national
policies that facilitate healthier choices. Worthwhile public
health policies seen as a threat by multinational companies
will be opposed by them but active national and international networks of healthcare professionals, voluntary
organizations, charities and their supporters can match the
political power of these industries.
Keywords: health protection, policy, smoking, transport
The product
Many parallels can be drawn between cigarettes and private
motor vehicles. Both have a wide range of serious adverse health
effects on those who use them and those around them (Table 1).
Less severe effects are also widespread: the nuisance of eye irritation or road traffic noise, the smell of cigarette smoke or
motor vehicle exhaust, and precipitation of symptoms in people
with asthma.
The consumer (Tables 2–4)
Smoking prevalence goes through three phases. Currently,
countries of Central and Eastern Europe (CEE) and the developing world are experiencing an exponential rise (phase ‘a’). The
number of smokers in many countries in Europe, for example
Greece, Germany, Italy and Denmark, has reached a plateau
(phase ‘b’), whereas prevalence in the United Kingdom, United
States, Canada and Australia is declining (phase ‘c’). Both early
adopters and early quitters come from the more educated and
wealthier members of the population. The social class pattern
alters markedly, with more affluent smokers in phase ‘a’, no
social class gradient in phase ‘b’, and a marked inverse gradient
in phase ‘c’, with smokers found mostly among the more disadvantaged in society. Women usually start smoking later than
men within any country, with a lower peak prevalence as health
education and other tobacco control measures are implemented
as evidence of harm accumulates.
Car ownership in the United Kingdom is still in phase ‘a’,
with continuing but decreasing inequalities in car ownership by
age, sex and income (Figure 1a). We do not know whether the
rise will continue, with more cars per household, or whether it
will stabilize then decline, like smoking (Figure 1b). There is
now a small but increasing number of people who choose not
to own a car or to leave it at home for many journeys. Like
smoking, car ownership is also increasing in CEE, Far Eastern
and developing countries, as they aspire to a ‘western’ lifestyle.
Use of both these products demonstrates aspects of
behavioural addiction, although cigarettes, as nicotine-delivery
devices, also cause physical addiction.1 Smoking is usually associated with a number of other adverse lifestyles, such as poor
diet and lack of exercise.2,3 Those with access to a car walk and
cycle less.4
The industry
Both the tobacco and the automobile and oil (auto/oil) industries are dominated by a small number of multinational corporations. This gives them political and financial clout, with the
power to influence governments. A major difference between
the industries is in their responses to awareness of their products’ unwanted effects.
The tobacco industry lied,5 promoted dispute,6 paid scientists to muddy the waters7 and have opposed regulation at every
step.5 Voluntary restriction and legislation to curb or ban advertising have been fought vigorously. The auto/oil industries have
Department of Epidemiology and Public Health, Imperial College,
St Mary’s Campus, Norfolk Place, London W2 1PG.
Jennifer Mindell, Honorary Clinical Lecturer
E-mail: [email protected]
© Faculty of Public Health Medicine 2001
Respiratory illness in children 5 years30
Asthma admissions
Cardiovascular admissions
Total
Hospital admissions in
non-users p.a.
*Totals may not add up because of rounding.
†Source: RCP 2000.1
‡Assumes average of 32 years of life lost per road traffic death (K. McMahon, personal communication).
Years of life lost before 75
4300
420
365
600
12000
17685
Miscarriages30
Perinatal deaths (stillbirths and early neonatal deaths)30
Sudden Infant Death Syndrome30
Lung cancer 32
CHD32
Total
Deaths p.a. in non-users
in the UK
551000†
17219
Speculative
Speculative
17219
109000
112000
134000
14100
5700
364200*†
Cancers
COPD (84%) and pneumonia (23%)
Circulatory diseases (e.g. 30% of CHD, 17% of strokes)
Other
Admissions prevented by smoking
Total (1997–1998)
Hospital admissions in
current and former users
p.a.
34200
37700
45100
2000
1400
117400*†
COPD (84%) and pneumonia (17%)
Cardiovascular diseases (e.g. 17% of CHD, 10% of strokes)
Cancers (e.g. 84% of lung cancer)
Other
Deaths prevented by smoking
Net total (1997)
Deaths p.a. in current and
former users in the UK
Tobacco industry
Table 1 Burden of disease attributable to the tobacco and auto/oil industries
Road traffic deaths in car users‡
Road traffic deaths in other road users
PM10 and NO2 air pollution31
Serious road traffic injuries 1999 other than car occupants4
Admissions attributable to a sedentary lifestyle in those
not allowed or too frightened by traffic to walk or cycle
Total
PM10 and NO2 air pollution31
Road traffic deaths 1999 other than car occupants4
Deaths attributable to a sedentary lifestyle in those not
allowed or too frightened by traffic to walk or cycle
Total
Serious road traffic injuries 1999 – car users4
Heart attacks and strokes attributable to a sedentary
lifestyle
Total
Road traffic deaths 1999 – car occupants4
Cardiovascular deaths attributable to a sedentary lifestyle
(e.g. 50% of CHD, 25% of strokes)
Cancer deaths attributable to a sedentary lifestyle
Total
Auto/oil industries
~50000
~55000
Speculative
39641
19200
20441
Speculative
9836
8100
1736
Speculative
18681
18681
Speculative
Speculative
1687
1687
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JOURNAL OF PUBLIC HEALTH MEDICINE
93
LESSONS FROM TOBACCO CONTROL
tomers and governments or has been suppressed. Low-nicotine
and low-tar cigarettes were designed to give low readings on
machines but the microscopic vent holes (through which air is
drawn in to reduce the tar and nicotine levels) are positioned
where most smokers automatically block them with their lips or
fingers.9 The bio-availability of nicotine has been manipulated.1
accepted regulation, albeit with vigorous negotiations. For
example, motor manufacturers are discussing with European
regulators to what extent the industry can or should change
vehicle design or construction to reduce injuries to pedestrians
hit by cars.8
Technology is used by tobacco manufacturers to trick cusTable 2 Smoking and driving by age
% Smoking prevalence,
1998
Weekly cigarette consumption
per smoker, 1998
% Driving licence holders,
1997–1999
Age
Men
Women
Men
Women
Men
Women
16–19
20–24
25–34
35–49
50–59
60
30
42
37
32
26
15
33
40
33
28
26
16
122
117
108
72
96
91
71
80
85
102
103
84
All
Combined
28
46
80
90
91
89
84
64
82
39
69
76
75
67
51
22
59
16–19
20–24
25–34
35–49
50–59
60
26
106
17–20
21–29
30–39
40–49
50–59
60–69
70
91
27
98
70
Sources of data: tobacco use, Ref. 18; driving licence holders, Ref. 4.
Table 3 Smoking and driving by socio-economic group
Professional
Managers
Intermediate
Junior NM
Skilled M
Semi-skilled M
Unskilled M
All
% Smoking
prevalence, 1998
Weekly cigarette consumption
per smoker, 1998
Households with
no car 1996 (%)
Men
Women
Men
All
15
21
14
20
91
104
65
85
24
24
98
89
32
37
42
28
29
32
31
26
115
112
120
97
102
100
Women
5
4
15
28
12
33
45
30
106
NM, non-manual; M, manual. Sources of data: tobacco use, Ref. 18; car ownership, Ref. 33.
Table 4 Smoking and drinking by quintile of household income
Highest
4th quintile
3rd quintile
2nd quintile
Lowest
All
Weekly cigarette expenditure
per household
1998–1999 (£)*
Weekly tobacco expenditure
per household
1998–1999 (£)*
Distance travelled by car
or motorcycle p.a.
1996–1998 (miles)†
Total distance
travelled p.a.
1996–1998 (miles)†
All
All
Men
Women
Men
Women
5.05
6.35
6.40
5.05
3.65
5.30
5.55
6.95
6.95
5.65
4.00
5.80
10762
8133
6155
4020
2606
6627
7729
5943
4259
3100
2025
4560
13057
9504
7167
5064
3654
8002
9297
7034
5289
4232
3032
5715
*Data from Family Expenditure Survey 1998–1999, Office for National Statistics.
†Data from National Travel Survey 1997–1999 (D. Hird, personal communication).
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JOURNAL OF PUBLIC HEALTH MEDICINE
Industry knowledge of how to reduce or eliminate some of the
most potent carcinogens in tobacco (e.g. nitrosamines) was not
used,10 as producing ‘safer’ cigarettes would have been tantamount to a public admission by the industry that existing products were not safe.
The auto/oil industries, on the other hand, have embraced
the technical fix approach. To decrease air pollution, they have
reduced the sulphur and lead content of fuel, developed threeway catalytic converters and particle traps, and agreed more
stringent restrictions on emissions from new vehicles. To protect
car occupants from injury after a collision, they have introduced
airbags and side impact protection.
However, the technical fix approach yields far less public
health benefit than a broad raft of policies to reduce use. Many
smokers with health concerns switched to low-tar or lownicotine cigarettes instead of quitting, but this is often compared
with ‘jumping off a four-storey instead of a 10-storey building’.
Reduced personal risk for drivers may, through risk compensation, lead to more risk-taking and therefore a higher chance of
collision, increasing injuries to other road users. A comprehensive tobacco control strategy aims to increase cessation and
reduce uptake of smoking. An integrated transport policy that
improves public transport and reduces the volume and speed of
traffic brings the benefits of reduced air pollution plus fewer and
less serious injuries, less noise and community severance, and
increases physical activity, access and equity.
The environment
Production
Environmental degradation is caused by both industries.
Deforestation in tobacco-growing areas occurs to clear land for
cultivation but especially to provide wood for curing tobacco.
Chemical use of both pesticides and fertilizers is extremely
heavy.11 Manufacturing cars is a heavily energy-dependent process.12 Environmental disasters occur when oil spills from damaged pipes or tankers.
Use
Tobacco smoke is the commonest cause of indoor air pollution
and motor vehicles of outdoor air pollution in more economically developed countries. Road traffic accounts for 34 per cent
of the United Kingdom’s energy consumption and is the source
of 24 per cent of the United Kingdom’s emissions of carbon
dioxide,13 the major contributor to global warming with its
potential effects on human health.14
For most of the last half-century, more economically developed countries have been designed for these industries’
customers. Non-smokers have only recently had areas where the
right to breathe smoke-free air has superseded people’s wish to
smoke. This is still far from universal, with the government
blocking the Health and Safety Executive’s Approved Code of
Practice.
Figure 1 (a) Trends in car ownership per household. , one or more cars; , two or more cars; , three or more cars. Source of
data: Transport statistics Great Britain 2000.4 (b) Trends in cigarette smoking by sex. , male (TAC); , male (GHS); , female
(TAC); , female (GHS). Sources of data: TAC (Tobacco Advisory Council);34 GHS (General Household Survey).35
LESSONS FROM TOBACCO CONTROL
Similarly, land-use planning has in most cases assumed car
ownership, with poor access for non-car-users.
Disposal
A total of 200 million cigarette butts and 20 million packets are
discarded in the United Kingdom each day, many onto the
ground, accounting for 40 per cent of street litter.15 Every year,
eight to nine million vehicles are disposed of in the EU, each one
generating a tonne of waste. The metal is recycled but 2 million
tonnes are sent to landfill sites as hazardous waste.16
Product promotion
Both industries use advertising to sell an image, not reality.
Wide-open spaces and mountain scenery distract us from the illhealth and pollution their products cause. The freedom portrayed is in marked contrast to users’ dependence on their
products, the number of people killed or harmed by them, and
the congestion experienced by most urban motorists. Codes of
practice on tobacco and car advertisements have been widely
flouted.8,17
Health promotion strategies
Over two-thirds of smokers would like to quit.18 This is not true
of drivers. The main benefit of private car use is warm, dry,
Figure 1 Continued.
95
door-to-door travel for driver, passengers and luggage, without
needing close contact with strangers. Once a car is bought and
annual costs are paid, marginal travel costs are extremely small
compared with public transport. In the last 25 years, motoring
costs have not changed in real terms (1998 index 99.3 relative to
100.0 in 1974), whereas rail and bus fares have increased sharply
(rail 150.2; bus and coach 170.8).4
For smokers trying to reduce harm, cutting down seldom
works. Those whose consumption does not increase again may
save money but as they usually inhale more deeply and leave
shorter butts, their nicotine (and tar) intake remains little
altered.1,9 Driver behaviour, however, is more likely to be
changed by reduction than stopping. Congestion charging,
charges for car parking and travel blending,19 where transport
patterns are examined to allow access with fewer journeys, are
all ways of reducing car use.
Control policies for both products are similar: education,
encouragement, counter-advertising; fiscal measures; regulation
of design; regulation of advertising; technical fixes to reduce emissions; enforcement; legislation; promoting less-harmful options.
Education is a necessary prerequisite for the effectiveness
of other tobacco control policies but is not very effective by
itself, although it is widely advocated by the tobacco industry.20
Measures known to be effective in reducing smoking are actively
opposed by tobacco companies.20 There is an equally effective
road lobby.
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JOURNAL OF PUBLIC HEALTH MEDICINE
Minimum ages for being sold tobacco or obtaining a driving
licence are designed to protect young people (and, in the case of
driving, the general public) from behaviours for which they are
too young to make mature decisions or exert control. However,
this, in combination with glamorous, witty advertising that
associates the activity with success, masculinity or femininity,
leads to these ‘adult’ activities having an added desirability and
mystique.
Where smoke-free areas or car-free days or areas have been
introduced, they have usually been well liked, despite initial
opposition, and are good for business.21,22 Staff transport policies are at the stage no-smoking policies were 20 years ago: a
minority of hospitals and local authorities have them, although
they are officially encouraged. Studies have also shown net job
creation from reducing cigarette consumption23 or traffic.24
It is unlikely that litigation will be as useful in promoting sustainable transport policies as it has in revealing internal tobacco
industry information and challenging the industry’s power.
The future
I see two main public health challenges. First, how do we change
social attitudes to car use? Media advocacy has been a powerful
tool in tobacco control25,26 and in drinking and driving.27 It is
time to challenge social norms relating to transport. Why are
traffic offences such as speeding not considered by the public or
police as a criminal offence with serious consequences? We
should confront assumptions that car use is the best way to travel
or a right. Fiscal policies cause problems for government when
they are not acceptable, as was shown by the fuel protests of
2000. Smokers and drivers feel they pay too much, yet they are
unaware of the many externalities (the external costs of transport not paid by private transport users or public transport providers), such as the health and environmental costs to society.
We also need to change the language, to frame the issues. Why
do politicians and the press talk of ‘investing’ in roads but ‘subsidizing’ public transport? Should the daily 10 deaths on UK
roads and 334 from tobacco share media invisibility?
Second, how do we change conditions to make ‘the healthy
choice the easy choice’? Governments can encourage substitutes
for cigarette or cars by, for example, making nicotine replacement therapy more readily available or improving bus services.
The White Papers on Tobacco Control and an Integrated Transport Strategy were warmly welcomed for their broad raft of
measures but we still await delivery. Powerful industry lobbies
can prevent or dilute legislation that they believe will harm their
profits,28 and negotiated agreements have proved of little use in
tobacco control.29
British doctors, subjects of Doll and Bradford-Hill’s cohort
study, were the first group to stop smoking. The Royal College
of Physicians of London and the British Medical Association
initiated campaigning for tobacco control; banning tobacco
advertising has been a slow process but is now accepted policy in
the United Kingdom. Tobacco control has shown that collab-
oration by national and international networks of healthcare
professionals, voluntary organizations, charities and their
supporters can match the political power of these industries. As
with smoking, we need to lead by example in both our personal
behaviour and our professional roles.
Acknowledgements
I thank Judith Cohen, Drew Hird, Laura Radiconcini and
Amanda Sandford for supplying data, and Amanda Sandford
and Dr David Cohen for helpful comments on an earlier draft of
this paper.
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Accepted on 5 February 2001