If present trends continue, experts predict, the tobacco toll in the 21st century will reach one billion premature deaths, ten times the 100 million people who died from tobacco use in the 20th century. To avert that future will require changing the focus of current tobacco control strategies from a primary focus on changing the behavior of present and future smokers to one that seeks to change the practices of the tobacco industry itself.
Without a more direct effort to change the practices of the powerful corporations that drive the world's leading cause of death, ending the tobacco epidemic will remain a distant goal.
Last week, two events shed light on current strategies the global tobacco industry uses to counter threats to profitability. In London, shareholders of British American Tobacco (BAT) and in Winston-Salem, Reynolds shareholders approved a BAT buyout of Reynolds that will create the world's largest tobacco company. In Geneva, the World Health Organization (WHO) released its 2017 report on the global tobacco epidemic, calling on member states to counter the rising tide of tobacco corporate lobbying and litigation that undermines public health measures around the world.
Effective tobacco control will require responding to four global trends. First, the tobacco industry is consolidating. By approving BAT's buy-out of the 57 percent of Reynolds it didn't already own, the shareholders made Big Tobacco a more powerful and concentrated threat to global health. With the merger, BAT and Altria, the maker of Marlboros, will sell eight of the ten top U.S. cigarette brands. In Asia, the largest tobacco companies in Japan, China and South Korea are buying up smaller rivals throughout the continent, further consolidating the world's largest market for tobacco. In 2016, the world's top five tobacco companies sold enough cigarettes to produce more than 300 smokes for every man, woman and child on the planet, with total sales of $150 billion. Consolidation gives bigger companies more to spend on marketing, lobbying, campaign contributions, and litigation, strategies used to undermine public measures to reduce tobacco use.
Second, the tobacco industry is becoming more skilled at interfering in government operations. Big Tobacco learned that occupying government is an effective complement to resisting government. For example, the industry has placed key allies within President Trump's administration. Vice-President Mike Pence claimed in 2001 that "smoking doesn't kill," and has since been a regular recipient of tobacco campaign contributions. Health Secretary Tom Price has long connections to the tobacco industry, and FDA head Scott Gottlieb served on the board of an e-cigarette company. Trump's nominee for Solicitor General, Noel Francisco, represented Reynolds in its successful lawsuit against graphic warning labels on cigarette packs.
In Africa, a growing market for tobacco, the Guardian reports that BAT and other transnational tobacco corporations have threatened at least eight governments, insisting that they repeal, delay or dilute public health measures to reduce tobacco use. "Tobacco industry interference in government policy-making represents a deadly barrier to advancing health and development in many countries," said Dr. David Bettcher, director of WHO's Department on Prevention of Noncommunicable Diseases.
A third trend is the tobacco industry focus on marketing to vulnerable populations. In the United States, poor people are have become a prime target. Compared to three decades ago, more of the 45 million Americans who still smoke are low-income. They have less access to cessation programs, more life stressors that trigger nicotine addiction and are more likely to be targeted by the $9.1 billion a year the tobacco industry spends on marketing. In Africa, women, young people and those moving to cities are the favored targets of tobacco marketers. Between 2010 and 2030, the number of smokers in Africa is expected to grow by 40 percent. As a result, tobacco use will widen current global and domestic gaps in premature death and preventable illness rates between the well off and poor.
Fourth, tobacco continues to be a profitable industry across the globe. In the United States, reports the Wall Street Journal, the operating profits of U.S. tobacco manufacturers have grown 77 percent between 2006 and 2016. This country generates more tobacco profits than any other market in the world outside China. Although smoking rates in the U.S. have declined, the number of smokers has stayed stable and addicted smokers guarantee that steep price increases lead to rising profits.
To reverse the trends that are helping Big Tobacco thrive and prosper will require health officials and advocates to rethink their goals and strategies. Without a more direct effort to change the practices of the powerful corporations that drive the world's leading cause of death, ending the tobacco epidemic will remain a distant goal.
Bringing tobacco litigation into the 21st century and extending it globally could help to thwart the new strategies Big Tobacco uses to defeat public health measures.
In the long run, only approaches that make tobacco companies less attractive to investors will deprive the industry of its lifeline of capital. In the 1980s, Warren Buffet explained why he loved tobacco stocks: "It costs a penny to make. Sell it for a dollar. It's addictive. And there's fantastic brand loyalty." But a few years later, he changed his mind. "I'm wealthy enough where I don't need to own a tobacco company and deal with the consequences of public ownership," he said. A reinvigorated global campaign to urge investment managers, hospital and university endowments, and pension funds to fully disinvest from tobacco would deprive the industry of capital and might make other investors decide, like Buffet, that profiting from a killer industry is not worth the reputational risk.
In the United States, lawsuits against Big Tobacco won new resources for prevention and treatment of tobacco addiction. Revelations in court documents discredited the industry, shrinking its outsized influence in politics. Bringing tobacco litigation into the 21st century and extending it globally could help to thwart the new strategies Big Tobacco uses to defeat public health measures.
Finally, taxes remain a pillar of effective tobacco control. Increasing tobacco taxes reduces consumption, especially among the most vulnerable groups, and provides new resources for effective prevention and treatment.
It took 50 years for the United States to cut smoking rates in half. By doing so, eight million lives were saved and 800,000 lung cancer deaths averted. With 100 billion lives around the world at stake, it's time to start disrupting business as usual.
