Toxicology 198 (2004) 9–18

Tobacco use and control: determinants of consumption,intervention strategies, and the role of the tobacco industry

Vera Luiza da Costa e Silva1, Burke Fishburn

Tobacco Free Initiative Department, World Health Organization, Geneva, Switzerland

Tobacco is a product that has been used by human-ity for centuries. Initially used in magic ceremoniesamong indigenous populations in the America’s re-gion its use was spread during decades in differentforms and to different groups. It was during the in-dustrialization period early in the 20th century that anoverwhelming population has taken up the so called“habit” of using tobacco. Different from what was ini-tially believed and only in the last 50 years the use oftobacco has been proven to be a causal factor in a se-ries of diseases. The further assumption that it causesdependence among its users and no longer was con-sidered an “habit” was key in understanding why onceinitiated its use and its consumption was maintainedand why the quitting process was so difficult. As aconclusion the use of tobacco products is responsiblefor an important slice of the global burden of diseasesand deaths. Recent estimates of global mortality at-tributable to smoking have shown that 4.83 milliondeaths world wide were due to smoking in 2000; fromthis 2.41 million deaths were from developing coun-tries and 2.43 million from industrialized countries(Ezzati and Lopez, 2003).

Tobacco use contributes to poverty as well. Stud-ies recently undertaken have shown that low income

1 Director Tobacco Free Initiative Department, World HealthOrganization. This presentation was prepared with inputs and sup-port from Carmen Audera-Lopez and Stella Aguinaga Bialous.

E-mail address: costaesilvav@who.int(V.L. da Costa e Silva).

households in Bulgaria with at least one smoker spent10.4% of their total income on tobacco products in1995 (Sayginsoy et al., 2002). It also affects devel-oping countries; in China, smokers surveyed in 2716households of the Minhang district reported spending17% of household income on cigarrettes (Gong et al.,1995).

Tobacco agriculture also has a negative environ-mental impact since trees are cut down to dry tobaccoleaves, and on the other hand the crop depletes soilfertility.

For all these reasons, if 100 years ago they knewas much as we know now, tobacco would with allcertainty never have been traded and if so, societywould have considered to it, among other possibili-ties.

1. Effects of smoking on health

Smoking is responsible for the death of one in 10adults worldwide (almost 5 million deaths per year)and, if current smoking patterns continue, by 2030 theproportion will be one in six (about 10 million deathsper year) (The World Bank, 1999). This means thatabout 500 million people alive today will eventuallybe killed by tobacco (Peto et al., 1994).

Since the 1950s, more than 70,000 scientific articleshave left no doubt that smoking is an extraordinarilyimportant cause of premature mortality and disabil-ity around the world. In populations where cigarette

0300-483X/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.tox.2004.01.014

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smoking has been common for several decades, about90% of cases of lung cancer, 15–20% of cases of othercancers, 75% of cases of chronic bronchitis and em-physema and 25% of deaths from cardiovascular dis-eases in those 35–69 years of age are attributable totobacco. Studies have shown that half of all long-termsmokers will die of a tobacco-related disease and, ofthese, half will die before the age of 65 (The WorldBank, 1999).

In 1994, the World Bank estimated that the use oftobacco results in a global net loss of US$ 200 billionper year, half of this loss being in developing countries.Costs were calculated to include direct medical carefor tobacco-related diseases, fire losses, absenteeismfrom work, reduced productivity, and lost income dueto early mortality (World Health Organization, 1998).

Fig. 1. The smokers body.

Cigarette smoking is a cause of several groups ofdiseases: cancers of a number of organs, cardiovas-cular disease, chronic lung diseases, and peptic ulcerdisease (Baron and Rohan, 1996). These diseasesoccur not only at the sites contacted directly by to-bacco smoke, the mouth, throat, and lungs, but alsoat sites reached by tobacco smoke components andmetabolites, such as the heart, blood vessels, kidney,and bladder. These diseases reflect carcinogenesis,atherogenesis, and chronic lung inflammation, thelatter probably arises through unfavorable balancesof oxidants versus antioxidants and proteolytic versusanti-proteolytic factors. Many of the diseases causallylinked to smoking are shown inFig. 1. Among thesediseases highlight ones are stroke, coronary heart dis-ease, aortic aneurysm, atherosclerotic peripheral vas-cular disease, chronic obstructive pulmonary, severalcancers including oral, pharynx, larynx, esophagus,lung, kidney, ureter, and bladder.

2. Effects of passive smoking on health

More than 50 studies of unvoluntary smoking andlung cancer risk in never smokers, specially spouses ofsmokers, have been carried out and published withinthe past 25 years. These studies show that there is astatistically significant and consistent association be-tween lung cancer risk in spouses of smokers andsecond-hand smoke from the spouse who smokes. Thisexcess risk is on the order of 20% for women and 30%for men. The excess risk increases with increasing ex-posure (IARC, 2003).

It has been described that there is an increased riskof suffering lower respiratory diseases in children ofsmoking parents (Odds Ratio 1.5–2) and an increasedrisk of asthma ( Odds Ratio 1.75–2.25) (CaliforniaEPA review, 1997). Similarly the risk of sudden in-fant death syndrome (SIDS) is higher amongst babieswhose mothers smoke (RR = 4.7) but also amongstbabies living in a house where only the father smokes(RR = 1.4) (Mitchell et al., 1993).

3. Tobacco epidemic

As a result of the experience across the 20th cen-tury in selected developed countries a model of the

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Fig. 2. (a) Conceptual model of tobacco epidemic. (b) Deaths in developed countries in the year 2000 attributable to selected risk factors.Source: NMH-WHO, 2003.

consecutive epidemics of smoking and smoking-relateddiseases in men and women has been created (Fig. 2).

Male prevalence shows a steady increase in the first50 years with a peak of approximately 60%. After thatpeak, prevalence declines to reach a plateau of approx-imately 40%. In most countries, the epidemic startslater for women than men. The female prevalence fol-lows the male prevalence pattern to reach a peak of40%, 20 years later.

The rise in tobacco-related mortality three or fourdecades later mirrors almost exactly the rise in smok-ing prevalence, reflecting the fact that many peoplesmoked for decades before getting a smoking-relateddisease. The same pattern holds true for both men andwomen. It is interesting to note that, because of thelong time lags, smoking-related diseases increase atthe same time that smoking prevalence is decreasing(stage 3). One message of this model is clear: by the

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Table 1Smoking prevalence (%) in selected countries. Source: tobaccocontrol country profiles

Smoking prevalence

Men (%) Women (%) Total (%) Year

China 53.4 4.0 28.9 1998Korea 64.8 5.5 35.00 1996India 29.4 2.5 16.0 1999Cote d’Ivoire 42.3 1.8 24.4 1997Chile 44.1 33.6 40 2001United Kingdom 28.0 26.0 27.0 2001United States 25.7 21 23.3 2000

Source: tobacco control country profiles-2003.

time that tobacco-caused deaths are evident, severalgenerations have become addicted.

Countries throughout the world are at differentstages of the tobacco epidemic (Table 1).

4. Mortality attributable to smoking

Sub-regions in the world have been classified ac-cording to their economic development and mortalitypatterns into developed countries, developing coun-tries with low adult low child mortality and developingcountries with high mortality (World Bank and WHO,2002).

Fig. 3. Deaths in 2000 attributable to selected risk factors in Low mortality developing countries. Source: NMH-WHO, 2003.

Tobacco is the risk factor responsible for the highestnumber of deaths in developed countries after highblood pressure (Fig. 2).

A similar pattern is observed nowadays in low mor-tality developing countries like China, where tobaccois the second leading risk factor for death after highblood pressure (Fig. 3).

5. Nicotine addiction

Inspite of all the evidence about the health effectsof tobacco and the increased risk of mortality, peoplecontinue to smoke because nicotine in tobacco is veryaddictive.

Nicotine in tobacco smoke reaches the human brainabout 10 s after the smoker inhales a puff. Nicotinebinds to nicotinic receptors located in the brain. Nico-tine in tobacco smoke increases the number of nicotinereceptor sites in the brain by two-to three-fold, and thisnicotine receptor proliferation may not be reversiblein humans. This fact contributes to enhance the addic-tive properties of nicotine. Acute nicotine administra-tion provokes perceptions of pleasure and happiness,increased energy, and motivation, increased alertness,increased feeling of vigor, increased cognitive arousal,and increased alertness, similar to that produced byother addictive drugs like heroin or cocaine. reduces

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appetite, contributing to smokers’ lower weight com-pared to non-smokers.

Adolescence is the time of life when most tobaccousers begin, develop, and establish their behavior.If adolescents can be kept tobacco free during theirteenage years most will not become smokers (USDepartment of Health and Human Services, 1994).Many young smokers are addicted to nicotine andsuffer withdrawal symptoms when they try to quit.

Tobacco use is described as a ‘gateway drug’ imply-ing that most young people that use harder drugs likemarijuana, cocaine or heroine had previously smokedtobacco.

6. Tobacco control

Tobacco control efforts can be classified in variousways. The World Bank classifies interventions as thoseaimed at decreasing demand for tobacco and thoseaimed at decreasing the supply of tobacco (The WorldBank, 1999).

6.1. Measures to reduce demand

These measures include interventions to decreaseaffordability (such as raising the price of tobaccoproducts) and acceptability (such as mass media cam-paigns, bans on advertising, and creating smoke-free

Fig. 4. Cigarette price and consumption per person per year in 22 European Countries. Source: Townsend 1998.

environments). Results show that four interventionsrequiring government action are very effective in allsub-regions.

• Taxation (most effective of all) The higher therate of taxation the more effective this interventionwould be) (Fig. 4).

• Clean indoor air laws.• A comprehensive ban on advertising.• Information dissemination on the health risks of

tobacco.

(i) Taxation: In spite of the addictive nature of smok-ing, demand for cigarettes is highly affected byprice. The extent to which smokers can affordto purchase cigarettes (affordability) has a majorinfluence on consumption. However, the demandis inelastic. It is not one to one, as a 10% in-crease in tobacco prices has been shown to reduceconsumption in the short-term by 3–5% in highincome, developed countries and by 8% in low-and middle income countries. Increasing pricesthrough taxation is considered to be the most ef-fective single tool to control tobacco use. Reduc-tions are greatest in children and in lower-incomegroups (Townsend, 1996).

Within the European Union, cigarette pricesvary both absolutely and relative to incomes.Fig. 4 is based on price and consumptiondata from 22 European countries taken from a

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cross-sectional study of smoking and price con-ducted in 27 European countries. The study re-ported a price elasticity of demand for cigarettesin Europe of−0.4 (a 1% rise in relative cigaretteprice results in about a 0.4% fall in the amountconsumed) (Townsend, 1996).

(ii) Clean indoor air laws: Tobacco control initia-tives in all countries must include control ofpassive smoking. Comprehensive smoke-freepublic places legislation must be introduced andenforced in order to protect the public fromenvironmental tobacco smoke at these places.

Reducing passive smoking at home, requiresan approach other than legislative measures giventhe private and intimate nature of the place. It is amatter of information, education, conscientious-ness, and social communication. Study carriedout in Latvia and Poland where tobacco con-trol measures such as, mass media campaigns,training programs for health professionals etc.included direct awareness raising to teachersand parents about the adverse effects of passivetobacco smoking in the home. This interventionresulted in a marked decrease in the number ofchildren exposed to tobacco smoke in the house(WHO/US EPA project, 2004). A similar studyis now taking place in China and Vietnam.

Fig. 5. Registered annual sales of cigarettes and tobacco consumption per adult 15+ in Norway Five year means 1950/′51–1999/2000+ mean 2000/′01–′01/′02. Source: Directorate of customs and excise, Norway.

(iii) Comprehensive ban of advertising: This includesadvertising in newspapers, magazines, radio, TV,bill boards, etc. Norway was the first country toban tobacco advertising in 1975. This measureresulted in an important reduction in cigarettessales and consumption (Ban on Advertising andpromotion in Norway, 2004) (Fig. 5).

(iv) Information dissemination: The general public,health professionals, policy makers etc. have toknow the true facts about the harmful effects oftobacco smoking and exposure to tobacco smoke.Counter advertising is necessary to compensatefor tobacco industry’s strategies to gain, moreand more addicts specially amongst children andwomen.

Since the 1960s, many governments have re-quired cigarette manufacturers to print healthwarnings on packages. Studies conducted inAustralia, Canada and Poland suggest that healthwarning labels, when prominent and containingspecific information, can be effective.

A study conducted in Australia showed thatthe implementation of stronger warning labelsresulted in a 27% increase in the percentage ofpeople noticing the labels, and a 7% increasein people forgoing smoking due to the labels(Borland, 1997).

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According to Health Canada, in order to beeffective, information required on labels shouldbe, “noticeable (stand out and be large enough toread), believable (relevant and factual), and re-callable (location and color should influence theability to remember)” (Health Canada, 2004).Two countries, Canada and Brazil have compul-sory health warnings with pictures on cigarettepackages.

For the past 3 years the 31st of May has beendeclared World No Tobacco Day by WHO.

Each year a different theme is chosen; forinstance, in the year 2001 the theme was pas-sive smoking, in 2002, Tobacco free sports andin 2003 Tobacco Free Films and Tobacco FreeFashion. Countries worldwide have participatedin this World No Tobacco Day carrying outdifferent activities organized for the occasion.

(v) Smoking cessation: Despite the tragic health con-sequences of smoking, health care professionalsoften fail to assess and treat tobacco use consis-tently and effectively. This failure to assess andintervene exists even when there is substantialevidence that even brief smoking cessation treat-ments can be effective. Support for smoking ces-sation or “treatment of tobacco depence” refers toa wide range of techniques including motivation,advice and guidance, counselling, telephone andinternet support, and appropriate pharmaceuticalaids, all of which aim to encourage and help to-bacco users to avoid subsequent relapse (WHO,2003). Brief advice to smokers given by a familydoctor during a routine consultation can resultin up to 5% of smokers quitting. Smoking ces-sation interventions, if delivered in a timely andeffective manner, greatly reduce the smoker’srisk of suffering from a smoking-related disease.Brief tobacco dependence treatment is effective,and every patient who uses tobacco should beoffered at least brief treatment. There is a strongdose-response relationship between the intensityof tobacco dependence counseling and its effec-tiveness. Numerous effective pharmacotherapiesfor smoking cessation now exist. Except in thepresence of contraindications, these should beused with all the patients attempting to quitsmoking. First-line therapy includes: bupro-pion SR, nicotine replacement gum, nicotine

inhalators, nicotine nasal spray and nicotinepatch; second-line therapy includes: cloni-dine and nortriptyline. Tobacco dependencetreatments are both clinically effective andcost-effective relative to other medical and dis-ease prevention interventions (U.S. Public HealthService, 2000).

Smoking cessation is beneficial at all times. Itis never to late to quit smoking, A prospectivestudy carried out amongst lung cancer patients re-vealed that those who quit smoking had a greatersurvival rate after 2 and 5 years than those whodid not quit (Schnoll et al., 2004).To quit smokingis possible and desirable. It is the only way to re-duce tobacco-related mortality in the next years.

6.2. Measures to reduce supply

As outlined by the World Bank report, theoreticalsupply-side interventions to control tobacco use in-clude prohibition of tobacco, restricting tobacco salesto youth, crop substitution, and diversification, restric-tions on international trade and action against smug-gling.

In general, the report concludes that there is littlepromise in most supply-side interventions. They arecharacterized as either politically or economically un-feasible, or unlikely to be effective, or both. The re-port, however, does make an exception for action toreduce smuggling, noting that this should be a keyelement in comprehensive tobacco control programssince smuggling can reduce price which is a criticaldeterminant of consumption (The World Bank, 1999).

7. Obstacles to tobacco control

Many factors are involved in the spread of tobaccoproducts use. Among the more important ones are themarketing strategies of the tobacco industry. The firstset of widely available tobacco industry documentswas a collection delivered to Professor Stan Glantz,as well as to the US Congress, of internal documentsfrom the BAT US subsidiary, Brown and Williamson.Analysis of these documents led to several researcharticles and a book: The Cigarette Papers, which isavailable online. Since 1994, several US states startedlitigation against tobacco companies to recover the

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costs to the state of treating tobacco-related diseases.In November 1998 the tobacco companies reached asettlement with the remaining 46 US states and theUS territories which were also suing to recover thecosts of treating people with tobacco-related diseases.In that settlement it was agreed that the tobacco doc-uments being produced to the public would be madeavailable in the internet, on websites maintained bythe tobacco companies. The settlement only includedthe US-based companies, so the BAT archives in Eng-land were not part of the settlement and did not haveto be available online.

The settlement of the Minnesota litigation con-tained a clause that required the tobacco companies tomake public all internal documents that were providedduring the disclosure process and that the companieshad to maintain archives of these documents for 10years. The US based companies had to maintain anarchive in the state on Minnesota, BAT had to main-tain an archive in Guildford, near London. Severalof the documents made public were documents thatthe industry had previously claimed were entitled toconfidentiality due to attorney–client privileges. Inaddition, the Minnesota settlement required the in-dustry to produce documents from other court cases,therefore, the archives are constantly being added to.

In general, the tobacco industry documents, both inGuildford and on the internet, cover these main areas:

• Effects of nicotine and addiction.• Tobacco-related diseases.• Second-hand smoke.• Cigarette ingredients and manipulation.• Marketing strategies.• Smuggling.• Competitors’ information.

They tell us that the tobacco companies knew aboutthe addictive powers of nicotine and the harms tohealth of cigarette smoking before anyone else in thescientific community knew about it. However, the in-dustry did not go public with this information. Like-wise, it tells us about the knowledge the industry hadabout the harmful health effects of exposure to tobaccosmoke, and the efforts it went to make sure measuresto provide clean indoor air were not widely adopted. Itdiscusses the development of cigarette brands and howingredients are manipulated to achieve different ob-jectives, and marketing strategies to reach the largest

possible number of people, smokers and non-smokers.There is also important information about the indus-try knowledge and involvement in the smuggling ofcigarettes as well as the assessment of each other’sposition in the world market.

8. Strategies to counteract the FCTC

It is clear that now that the FCTC is a reality, the in-dustry will attempt to block ratification, or to changethe articles of the FCTC in order to continue to protectits interests and its profits at the national level. Gov-ernments and legislative bodies need to be aware thatthe tobacco companies will put pressure in order thatonly the articles of the FCTC that it believes are ac-ceptable will be enforced. It is thus, important to knowwhat are the industry’s views of the FCTC terms.

9. Some examples on specific activities targeted tocountries by tobacco industry are

9.1. Second-hand tobacco smoke

The industry conducted studies and surveys, andused strategies to oppose implementation of cleanindoor air measures through the promotion of its ownprograms. Philip Morris website acknowledges thatventilation does not address health effects of expo-sure to tobacco smoke, but industry programs don’tdiscuss this fact.

“The ETS Consultants Project in Central and SouthAmerica (“Latin Project”) was initiated in early1991. The Latin Project currently includes thir-teen consultants from seven countries: Argentina,Brazil, Chile, Costa Rica, Ecuador, Guatemala, andVenezuela. The Latin Project currently receivesforty percent of its funding from Philip MorrisInternational. Unlike many other regional ETSconsultant programs sponsored by the industry, theLatin project was initiated in anticipation, ratherthan in reaction to, the full-force arrival of the ETSissue to Central and South America. Critical to thesuccess of the Latin Project is the generation andpromotion of solid scientific data not only withrespect to ETS specifically but also with respect to

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the full range of potential indoor and outdoor aircontaminants (ETS Consultants Project, 1992).”

9.2. Advertising and promotion regulation

The teenage years are also important because theseare the years during which most smokers begin tosmoke, the years in which initial brand selections aremade, and the period in the life cycle in which con-formity to peer group norms is greatest (Ezzati andLopez, 2003).”

The industry has maintained that the reason for ad-vertising and promoting their products was to inducesmokers to change brands. They also claimed that thereason most teenagers start smoking is their expo-sure to other smokers in the peer and family network.However, industry documents reveal that the goal ofpromotion and advertising is the recruitment of newconsumers.

Promotion strategies include sponsoring high-schoolsporting events, distributing free samples and arrang-ing for discos to provide free admission in exchangefor empty packs of cigarettes.

9.3. Packaging and labeling

When photo health warnings were introduced inBrazil, cigarette manufacturers introduced other photocards in the package which had the same shape andsize of the photo warning so that these could be cov-ered and therefore prevent the smoker from having tosee the unpleasant photo on his/her cigarette pack.

For Instance in Brazil advertising cards were (USDepartment of Health and Human Services, 1994) in-serted into cigarette packs by tobacco companies afterthe new health warning with photos began to circulatein Brazilian market. These cards had the same shapeand size of the photo warning for smokers to coverthe photo on the package. In other countries tobaccoindustries are giving out boxes to put in the cigarettepack and therefore hide the health warnings on packs.

9.4. Lobbying against a law

Tobacco Industry in Argentina created a campaignso that the president would veto the Neri Law whichhad been approved by parliament . Neri Law bans alltobacco advertising and promotion, restricts smoking

in public places and will force tobacco manufacturersto detail ingredients on package.

The campaign consisted in that influent Argentiniangroups would send letters to the then President CarlosMenem with the following arguments:

• The Neri law is an unconstitutional limitation to thecommercial expression freedom.

• There is no evidence of the association betweentobacco publicity and increased use of tobacco.

• Tobacco publicity is aimed at maintaining loyaltyto a brand name or to promote change in brand.

• The Argentinean Cardiologist Carlos Alvarez, per-sonal friend of the president, convinced him to vetothe law.

10. WHO–FCTC

Tobacco epidemic is expanding and increasing dueto a mixture of complex factors which surpass thenation’s boundaries amongst other reasons due toglobalization of tobacco industry marketing strategiesThis globalization of the epidemic limits the coun-tries capacity to regulate locally tobacco control. Aninternational commitment is required. For this reason,in 1999 WHO’s TFI initiated negotiations in order tocreate an international treaty on tobacco control. Af-ter very hard negotiations, WHO’s first public healthtreaty, the Framework Convention on Tobacco Con-trol, was unanimously adopted by the 192 memberstates of the World Health Assembly in May 2003.

The WHO–FCTC is a tool to achieve a global publicgood, i.e. the reduction of tobacco attributable diseasesand death.

It addresses issues as diverse as:

• tobacco advertising, promotion and sponsorship;• packaging and labelling;• regulation and disclosure of contents of tobacco

products and tobacco smoke;• illicit trade in tobacco products;• price and tax measures;• sales to and by minors;• government support for tobacco manufacturing and

agriculture;• treatment of tobacco dependence;• passive smoking and smoke-free environments;

18 V.L. da Costa e Silva, B. Fishburn / Toxicology 198 (2004) 9–18

• surveillance, research and exchange of information;and

• scientific, technical, and legal cooperation.

The convention is open for signature and ratifica-tion.

The signing of the WHO–FCTC indicates a Mem-ber State’s intention to ratify the treaty but does notcarry substantial obligations. The ratification of theWHO–FCTC commits a member state to implement-ing the provisions of the treaty. The WHO–FCTC willcome into force of law 90 days after the treaty hasbeen ratified by 40 member states with the establish-ment of the conference of parties.

Our new Director-General of WHO, Dr Lee hasurged countries to sign and ratify the WHO–FCTCas quickly as possible to prevent further loss of livesfrom tobacco-related diseases.

The FCTC negotiations have unleashed a processresulting in tangible differences at country level. Todrive this momentum, WHO calls on all tobacco con-trol advocates to strengthen the efforts made thus far.

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