Tobacco, global public health, and non-governmental organizations: an eminent pandemic or just another legal product?

• Author: Malcolm, David J.

"Smoking is the chief single avoidable cause of death in our society and the most important health issue of our time."(1)

"Tobacco products have no safe level of consumption, and are the only legal consumer products that kill when used exactly as the manufacturer intends."(2)

1. INTRODUCTION

   American actions and perspectives regarding tobacco have profoundly influenced the world in many ways. Health concerns first articulated by the Surgeon General in 1964(3) led to a new paradigm in how we view tobacco, public health, and smoking in general. The Surgeon General's 1964 report proved to be a watershed in America. It was the first of many government publications to detail the unhealthy medical effects of tobacco.(4) As a result, the U.S. government now regulates the formerly unfettered tobacco industry based, in part, on continuing medical revelations.(5) Despite a significant minority(6) of the American population that disagrees with the federal government, Congress and several executive agencies have enacted many laws and rules to regulate tobacco: including labeling,(7) advertising,(8) workplace rules,(9) and reporting.(10) Proposed federal regulations continue to surface.(11) The march to regulate tobacco consumption continues nationwide.(12) Anti-tobacco public announcements(13) and publications(14) are relatively common.

   America continues a leading role in the legal arena too. Tobacco litigation in America entered its third wave(15) when states sued the tobacco industry. States claimed that the industry committed fraud, deception, and racketeering upon the public, thereby creating a causal relationship between public smoking and excess state Medicaid expenses.(16) By focusing on the industry's actions in the third wave of litigation, and not the smokers' behavior, the states avoid the winning industry defense of assumption of risk because the states(17) are third parties that never smoked.(18) The tobacco companies settled out of court with the states, agreeing to payments totaling $206 billion over the next twenty-six years. Additional conditions of the settlement are bans on advertising directed toward teens and children, and tobacco company-funded study of programs to reduce teen smoking and prevent tobacco related disease.(19) Non-smokers adopted similar strategies to sue the industry.(20)

   Changing public perceptions and laws are like tremors that shake the tobacco industry's foundation. In 1997, California removed tobacco from a list of inherently unsafe consumer products that shielded manufacturers from product liability actions.(21) While in the 1970s Florida manufactured cigarettes and supplied them while in state prisons and hospitals, by 1994 Florida's position had changed diametrically from ratification to confrontation.(22) Congressional legislation may radically alter the present situation by shifting liability on a national scale.(23)

   Although recent events continue to alter the American legal landscape on a regular basis, an in-depth analysis of the changes in the third wave of litigation and legislative proceedings affecting tobacco are beyond the scope of this article. This article's discussion of the changing legal strategies and results is limited to a general analysis as applicable in a global context.

   Global attitudes concerning tobacco are similar to the predominate American perspective, but less pervasive in the public recognition of tobacco's dangers and set within a broader spectrum of beliefs, behaviors, and knowledge. Health issues are the leading reason for concern,(24) due in large part to world events in the later part of this century.(25) Several factors contribute to increasing tobacco consumption: rising living standards, the globalization of economies, technological innovations, and modern advertising.(26) Predictably, tobacco consumption increased dramatically in recent decades.(27) International and domestic health organizations are leaders in the anti-tobacco war.(28)

   This article analyzes global tobacco issues within the context of non-governmental organizations (NGOs). Part II reviews the health aspects associated with tobacco. Part III examines public education and awareness in a global scope together with local, regional, and international efforts and resultant effects. Part IV addresses tobacco's effects upon children. Part V studies the matter of tobacco consumption as a vehicle for drug delivery within the scope of substance control. Part VI surveys the wide ranging economic issues that involve tobacco, including advertising, taxes, and workplace conditions. Part VII notes the call for an international framework for tobacco control and analyzes desirable subject matter for inclusion. Part VIII concludes with a summary of suggested actions to increase the effectiveness of the worldwide anti-tobacco struggle.

2. TOBACCO AND HEALTH

   Although cigarettes are the most prevalent form of tobacco consumption, many other forms exist.(29) There are approximately 1.1 billion smokers worldwide, comprising about one third of the global population age fifteen and over.(30) Global estimates indicate 47% of men and 12% of women smoke.(31) Many smokers begin at an early age (in many countries the median age of initiation is below age fifteen), thereby lowering the age when a smoker will suffer smoking-related diseases and death.(32) As a result of nicotine addition, nicotine tolerance increases over time and causes smokers to increase their consumption to the extent they can afford.

   Tobacco is known to cause undesirable health effects. Medical sources cataloged the effects over the last few decades.(33) Although the tobacco industry and some others still generally dispute the medical knowledge implicating tobacco,(34) the tide has changed since the early 1960s. The addictiveness of nicotine is a material factor in continued tobacco consumption.(35)

   Smoking in developing countries became widespread in recent years. Trends indicate an increasing daily consumption per smoker as economic conditions improve worldwide.(36) Despite decreasing consumption in developed countries, the rapid increase in developing countries kept world consumption from decreasing.(37) While global cigarette consumption per adult remained steady through the early 1990s, global consumption increased as world population increased.(38)

   Increased tobacco consumption corresponds with burgeoning health effects on the world's population.(39) Costs are more than just individual health; they include environmental, quality of life, and economic costs.(40) While life expectancy lengthens, the risks of infectious diseases decreases and the likelihood of noncommunicable or chronic diseases increases.(41) Chronic diseases remain incurable and the best solution, presently, is prevention. Associated with this situation is the "epidemiological transition"(42) that occurs as the developing states become more developed. The improving world economic condition generally accelerates tobacco consumption (a detrimental lifestyle risk factor), the epidemiological transition, and the increasing burden of suffering and disease caused by tobacco. Fortunately, prevention or cessation of tobacco consumption are effective means of countering tobacco's ill effects.(43)

   Strong arguments exist for minimizing tobacco consumption. A simple economic argument posits that despite the short-term economic gains from tobacco,(44) the insidious nature of tobacco addiction and its long-term costs far outweigh the industry's economic value overall. In other words, if governments internalize the health care costs and lifetime productivity losses to offset tobacco benefits (e.g., jobs and revenues), the tobacco habit is a net drain on national economies overall.(45) A moral argument also exists for keeping adolescents from consuming tobacco or becoming industry targets.(46)

   International law supports a fundamental right to a healthy life,(47) and indirectly supports anti-tobacco public health efforts.(48) States are obligated to protect their citizens' health, but, within the anti-tobacco arena, such protection is slow in coming, if it comes at all. Naturally, the state interest in its citizens' health should be balanced with personal choice. While promoting a legal and broadly accepted product, along with the individual right to consume tobacco, the tobacco industry generally prevented states from acting upon their legal obligations to protect and improve public health in this arena. Fortunately, the tide is turning against the industry due in large part to relentless efforts of NGOs.(49)

   The increasing predominance of global tobacco consumption causes mixed opinions. Some organizations, for example the World Health Organization (WHO) and the U.S. Department of Health and Human Services (HHS), are quite alarmed by the trends and projected statistics.(50) The WHO's Constitution obligates it to minimize tobacco's unhealthy influence.(51) Although neutral in their stance, many governments implicitly condone the industry through their inaction. At the opposite end of the spectrum, the tobacco industry continues to zealously promote tobacco as a legal product. If one views the decades of medical research and present statistical projections as credible, then a question arises. What, if anything, should be done about tobacco consumption and global public health? This article examines the possibilities from a global perspective viewed within the context of NGOs, while trying to find a balance between personal choice, public health, and a legal commodity.

3. PUBLIC EDUCATION AND AWARENESS

   Cultural acceptance of tobacco is generally widespread and longstanding.(52) Tobacco has been a legal product since its introduction from the New World in 1492. Thereafter, it gained popularity despite King James' 1604 admonition that "[s]moking is a custome lothesome to the Eye, hateful to the Nose, harmefull to the Braine, [and] dangerous to the Lungs...."(53)...