The nicotine cartel.

• Author: McGinn, Anne Platt
• Position: Ill-effects of tobacco and cigarette smoking

Despite their legal problems in the United States, the tobacco multinationals continue to make a killing in the developing world. Record cigarette sales threaten a public health crisis that could overshadow all infectious diseases combined.

The fastest growing public health menace in the world isn't a disease in the ordinary sense of the term - it's a product. The consumption of tobacco has reached the proportions of a global epidemic. Tobacco companies are cranking out cigarettes at the rate of 5.5 trillion a year - that's nearly 1,000 cigarettes for every man, woman, and child on the planet. Already, one person out of every five is a smoker. And just as a successful pathogen adapts to changing conditions as it spreads, tobacco is proving adept at exploiting new markets. Within 25 years, tobacco-induced illness is expected to overtake infectious disease as the leading threat to human health worldwide.

Big tobacco owes its growth in large measure to its highly developed promotional strategies. The industry is dominated by seven multinational companies, which in 1995 accounted for almost 45 percent of global cigarette sales (see table, page 22). (The largest cigarette producer of all, the China National Tobacco Corporation, accounts for 32 percent of global sales, but because it sells only within China, it has little influence on the international market.) The sophisticated, big-budget marketing strategies used by the multinationals - especially Philip Morris, British-American Tobacco, and R.J. Reynolds - are increasingly setting the pace for the industry as a whole. In many parts of the world, tobacco marketing now involves a comprehensive mix of ads, sponsorship of cultural events, subsidized farm projects - even campaign donations.

The results mean addiction not only for individual smokers but for governments and societies as a whole. Tobacco sales and the tax revenues they generate often create a high degree of economic dependency. But this is a false economy if ever there was one: for every 1,000 tons of tobacco produced, nearly 1,000 people will eventually die from tobacco-related illnesses.

Worldwide, these illnesses are estimated to cost nearly $200 billion a year in direct health care expenses and lost productivity. One third of this cost - $66 billion - is already borne by developing countries, a total that is expected to skyrocket as smoking in those countries continues to grow.

But epidemics sometimes weaken as they spread, and the 1990s may prove to be the beginning of the end for the tobacco plague. In March 1997, the Liggett Group, the fifth-largest U.S. tobacco company, settled a lawsuit brought by 22 U.S. states who were attempting to recover the public health care dollars spent on treating victims of tobacco-caused diseases. As a part of the settlement, Liggett formally admitted the obvious: that nicotine is addictive and cigarettes are carcinogenic. Even though a medical consensus on these points had formed during the 1960s, this was the first time a tobacco company had acknowledged that it was selling an addictive product - a legal precedent that could cripple the industry. Liggett officials may have set an even more powerful precedent by verifying claims that the industry commonly targets its marketing efforts at teenagers as young as 14, in order to lure them into a lifelong habit. Anyone looking at tobacco advertising might think such an admission obvious too, but until this settlement, the industry invariably insisted that tobacco companies were targeting only adult consumers of competing brands.

Tobacco opponents in the United States and elsewhere are preparing to exploit these cracks in the industry's legal bulwark. The U.S. Federal Trade Commission, which monitors domestic business practices, is poised to reexamine "Joe Camel" advertising - the use of a cartoon character in ads for Camel cigarettes, which critics see as an attempt to recruit children. Courts in Canada, France, Great Britain, and the United States arc hearing more lawsuits, some filed by victims of tobacco-caused disease, others by jurisdictions saddled with the resulting public health expenses. Regulatory precedents are beginning to accumulate as well. Although enforcement is often weak, many cities now ban smoking from at least some of their public spaces - this is true of Delhi, India, many U.S. cities, and 27 Chinese cities including Beijing.

As a legitimate product, tobacco has seen its day pass. Even to officials reluctant to criticize the industry directly, there is little doubt now that nicotine is a dangerous, highly addictive drug that would never be legalized if it were discovered today. Overcoming the global tobacco addiction will require higher public awareness of the medical dangers, but that alone won't be enough. Policy makers and the general public will also need a clearer understanding of how the tobacco companies build their markets - and how societies come to depend on tobacco money.

COFFIN NAILS

When smokers light up, they inhale not just the nicotine they crave, but a mixture of some 4,000 other toxic chemicals, including carbon monoxide, cyanide, arsenic, formaldehyde, and lead. To this brew of poisons naturally present in tobacco, manufacturers may be adding other substances to enhance the rate at which nicotine is absorbed in the body. For example, a 1991 internal handbook used by one U.S. company, American Tobacco (now a subsidiary of British-American Tobacco), strongly suggests that ammonia may be introduced into cigarettes for this purpose.

Many of these substances have been linked to respiratory and cardiovascular disease. Chronic exposure to carbon monoxide, for instance, leads to difficulty in breathing, coughing, higher rates of respiratory infection, and an increase in the risk of heart attack. Bronchitis and emphysema are among smokers' most common respiratory ailments. Bronchitis frequently afflicts smokers soon after they take up the habit, and because it tends to stay with them, chronic bronchitis is the most expensive disability that tobacco causes. But cardiovascular disease is the way tobacco usually kills. Of the roughly 420,000 tobacco-related deaths every year in the United States, for example, nearly half of these are from heart disease and stroke.

Tobacco's second most common way of killing is cancer. In 1993, lung cancer accounted for about one quarter of all tobacco-related deaths in the United States. Smoking increases the risk of cancer elsewhere in the body as well - in the mouth, larynx, pharynx, esophagus, pancreas, kidney, and bladder. Tobacco caused cancers killed 1.1 million people worldwide in 1993, accounting for one out of every seven cancer deaths. And since there is usually a 20- to 25-year delay from the first cigarette to the appearance of a tumor, the spread of tobacco is expected to provoke enormous increases in cancer over the next couple of decades. Worldwide, tobacco is expected to more than double the incidence of lung cancer alone by 2020, from 945,000 deaths in 1990 to 2.4 million.

Tobacco may not kill until middle age or later but in a sense, it chooses its victims young. Some 90 percent of all smokers have their first cigarette by age 20. And the younger a person is at the time of that first cigarette, the more confirmed and heavier a smoker that person is likely to be as an adult. Consequently, children and young adults who smoke are at a much higher risk for later disease than are people who take up the habit when they are older. On average, smokers who light their first cigarette at age 25 lose about 4 years of life; those who start at age 15 lose 8 years.

It is the growth of tobacco use in the developing countries that will soon make it the world's leading killer. Richard Peto, an epidemiologist at Oxford University's Imperial Cancer Research Fund, calculated that tobacco killed 3 million people in 1995, 1 million of whom lived in developing countries. By 2025, Peto estimates, tobacco's annual death toll will reach at least 10 minion. More than 7 million of the victims will die in developing countries - a 700-percent increase in just one generation. If present trends continue, according to the World Bank's 1993 World Development Report, tobacco-related deaths will in 30 years' time exceed the death toll from AIDS, tuberculosis, and complications in childbirth combined.

Perhaps no other common product shows as great a disparity between its advertising imagery and the actual consequences of its use. Tobacco's growing, global toll of misery and death bears almost no relation to the mystique of youth, health, and physical vigor that industry ads so consistently present. Philip Morris never mentions that the man who posed for its Marlboro ads died from lung cancer.

THE TOBACCO INVASION

The modern...