• One billion deaths: The imperative of global tobacco control

    The recent deaths of Christopher Hitchens and Vaclav Havel provide a timely reminder that tobacco use is the most prevalent behavioral threat to life and health.

    In 2012, an estimated six million people around the world will die as a result of tobacco use. The World Health Organization projects that one billion people could die of tobacco-related causes over the remainder of this century. That’s an almost unfathomably huge number. If anything like this comes to pass, tobacco will numerically dwarf just about every other threat to human life and health.

    I ran across the numbers in my capacity as an assistant editor at Addiction, where I helped shepherd a manuscript concerned with smoking cessation in Vietnam. The rapidly developing economics of Southeast Asia face especially high tobacco-related health burdens. An estimated 47 percent of Vietnamese men (though fortunately very few women) smokes. Eighty-two percent of Vietnamese smokers smoke daily. Rising per-capital incomes, modern media, and globalization may well worsen the problem by lowering the economic and cultural barriers to tobacco use….

    Of course the same trends may create opportunities to help. Rising incomes may support the use of more costly and more effective prevention strategies and smoking cessation therapies. Globalization may promote the proliferation of best-practice models of smoking cessation in primary medical care and public health. Signatories to the World Health Organization Framework Convention on Tobacco Control (FCTC) now encompass 87 percent of the world’s population.

    In 2008, the World Health Organization initiated the MPOWER effort to encourage every nation to pursue a package of evidence-based measures. MPOWER includes a broad range of measures from epidemiological surveillance to smoke-free environments, warning labels, media campaigns and commercial advertising bans, tobacco taxes, and more. That’s a good start. Yet only a very small percentage of the world’s people receive the recommended help in primary prevention or in encouragement and practical help in halting their tobacco use. Many of these measures are extremely cost-effective when compared with other widely-accepted measures to prolong life and improve health. 

    Tobacco manufacturers, distributors, and end-sellers–firms that you’ve heard of, but many others, too—fight against many effective measures in the United States and across the world. The political economy of public health often works against effective measures, too.  Within many societies, it is easier to build political coalitions for medical treatment than for effective prevention measures. There’s more money to be made selling cigarettes and providing help and services to sick smokers than there is to be made preventing and halting tobacco use.

    Tobacco is no ordinary product. We need the same effectiveness and passion behind global tobacco control that one sees in the best efforts against AIDS. One billion lives are at stake. It’s hard to even imagine such a number. So it’s good to remember specific special people such as Hitchens and Havel. I would add two more: Gregory and Janice Perrone, both of whom died bad deaths from lung cancer before their grandchildren–my daughters–could really get to know them.

    • Harold, my friend, I happen to know you are far too smart for the role of “useful idiot” (I assume you read Krugman’s blog and will catch the reference to what he posted this weekend). You no doubt know that something like 99.999% of the deaths from “tobacco” are from smoking (an observation that does not require taking up a debate about the dubious nature of the estimates of the toll). You may not realize that the use of “tobacco” is not an accidentally misleading reference to smoking, but part of a concerted effort to discourage the most promising approach, harm reduction.

      You mention the effort against AIDS. I am sure you agree that if that effort had focused on prohibiting all sex outside of state-sanctioned heterosexual marriage and counted on eliminating injection drug use, it would have failed (and been intensely unethical). Just as reducing the harm from desired potentially dangerous behaviors is the way to deal with AIDS, it is the most promising approach to dealing with “tobacco”: substituting for high-risk tobacco use (smoking) the use of satisfying tobacco products that have comparatively trivial risk (smokeless tobacco, electronic cigarettes and inhalers, pharma products if they would ever make something that is appealing). Indeed, it is the only thing that seems to be able to get smoking prevalence below about 20% a population, once it becomes popular. Empirically, the only “effective measures” are simple education about the risk (functional literacy is necessary and almost sufficient), taxation (not always possible and maxed out in many places), and product substitution (the only proven measure that is not pursued to close to its potential).

      Anyone involved in anti-smoking who is seriously concerned about public health, rather than being driven to purify people who annoyingly refuse to “behave properly”, or making money from anti-smoking, cannot help but embrace harm reduction. Those in power behind global tobacco control do not fall into the public health category. Among the worst of the anti-public health approaches are FCTC and MPOWER (which is basically warmed-over decades-old policies, so you kind of have to wonder who really wants to replicate that level of “success” — maybe those who profit from ongoing, but never successful, anti-smoking efforts?). If the US makes the mistake of starting to obey FCTC dictates, which fortunately it currently ignores, there will be even less hope for harm reduction, which is the only serious hope for major beneficial change within a generation or two.

      No one favors the death toll from smoking. But if you really want to help fight it, do not fall into the trap of blindly supporting the powers that be, and their ideological or profit-driven pursuit of prohibition at the expense of public health.

      Oh, and I am not sure Hitchens would have had anything good to say with promoting harm reduction, but he definitely expressed disdain for the prohibitionist/nanny/vilification approach to trying to save him from himself.

    • I’m no proponent of smoking, but does the earth have the carrying capacity for the added population that eradication of tobacco use would produce?

    • Wow–long comment. As for the “useful idiot” trope, I guess it beats being called an “uptight little lesbian” as I was on the other post.

      I see tobacco harm reduction as a separate set of issues. I have inherent problem with the general idea of tobacco hr if it is backed up by clinical trials. These strategies are sometimes useful, sometimes not. Chewing tobacco is sometimes helpful. Filter cigarettes, otoh, killed many people by providing a tempting alternative to quitting.

      That is really quite a separate set of issues from the main tobacco control efforts in excise taxes, frank warning labels, and media campaigns, support for evidence-based smoking cessation treatment, etc. You are making a greater opposition than there needs to be here.

      If Hitchens expressed disdain for paternalism as one legitimate element of public policy, I guess I’d cite his own death in my opposing brief. I’m glad his smoking/boozy life choices are going out of style.

      • @Harold Pollack
        Random bit of info. In obituaries of local paper yesterday, there was one whose first line was “He died at age 52 of non smoking-related lung cancer.” I think sometimes we forget how far we have come in terms of smoking not being acceptable in our society.

    • Harold, Carl Philips is a long time tobacco industry consultant. He was most recently sharing the stage with them all at their closed conference in Prague. They love him to bits.

    • I think Carl’s point is that there is no legitimate reason to not say “smoking” or “cigarettes” to talk about the illness and death caused by tobacco. It’s a tactic that has been used in tobacco control for far too long, and it allows charlatans to demonize smokeless and smoke-free tobacco products.

    • Harold, You are totally right that there is not much disagreement. And you should note that I carefully tried to state that you far better than the legions of useful idiots that the anti-public-health tobacco control people have managed to recruit. I respond to you, and none of the hundreds of other people who wrote a column this month calling for use to do something about smoking, because I am confident that you can see through the bullshit. You are a good scientist, so if you think about it, you should be able to figure that the canard about “we need clinical trials” is just another tactic for trying to trick useful idiots into opposing the welfare maximizing approach, THR. We do not do clinical trials of educating the population about THR for the same reason we did not do them for educating people about the harm from smoking back in the 1960s, and for the same reasons: (a) we do not need to because we already are certain enough about what will happen, and (b) it is quite literally impossible. Where are the clinical trials of what happens when we put emotionally violent graphics on packages? Or remove the brand logo?

      Anyway, my point was (as Bill Harrison suggested) to urge you not to fall into the trap of believing the Big Lies of the huge industry that is anti-tobacco. You and I share the same goals, I believe: improving people’s welfare, as well as improving public health. It is not clear that those in power in anti-tobacco even share the latter goal, and it is quite clear they do not share the former.

      Oh, and Franco, you probably should not think of yourself as exactly clever for trying to introduce me to my graduate school office-mate. Oh, and if it was such a closed conference, how would you know who I shared a stage with. You tobacco control ad hominem types are really quite pathetic. If you have something useful to say, why don’t you say that instead …oh, wait, I think I know the answer to that.

    • I hate to beat a dead horse, but as a geriatrician practicing nursing home medicine I see the end of life of many whose lives were “saved” by one medical intervention or another. On the news I see millions who were saved from malaria to die of starvation. We don’t prevent tobacco-related deaths. We change the deaths from one form to another. I contend it is only fair to consider the consequences of what we advocate, not just to assume ‘things will be better.’

    • @Wally R your argument is a bit like saying “Let’s not prevent car crashes or fires or shootings. After all, those people were going to die anyway, some in a miserable old age, and some of them might do bad things with their extra years anyway.”

      Martin Luther King Jr. famously said, in the last speech he gave, the night before his assassination, “Like anybody, I would like to live a long life – longevity has its place”. Life is about both longevity and quality of life. And the tobacco industry deprives people of both, so better to risk trading one harm for another than being almost certain of a poor, tobacco-induced outcome.

      The reductio ad absurdum of your concern is that if we followed this you’d rarely do anything to make any kind of health-improving intervention because of the knowledge that it’s just putting off the inevitable.

      I’d say the most important thing is that the magnitude of the intervention needs to be considered. A palliative care intervention that adds 6 month of life expectancy to a frail 92 year old is pretty qualitatively different to something that has the potential to add 20 years of life expectancy in the middle years.

      • I see the problem a bit differently.

        Environmentalists have made the case that the Earth is presently occupied by many more humans than it can sustainably support. Jared Diamond, in Collapse, points out that where we’ve exhausted the supply of essential support elements in discrete parts of the globe, civilizations became extinct.

        We have only the options of facing the earths limitations and adapting to them or of ignoring its limitations and experiencing the consequences. How to adapt is a separate question with no apparent answer, politically or otherwise, at the moment. But to move forward as Medicine does, pretending that the extermination of disease is a universal good with no unintended consequences is to move forward with blinders on.

    • It makes no sense to treat tobacco-related death A (50-year-old dies from lung cancer) and tobacco-related death B (85-year-old dies from lung cancer approximately 6 months before the colon cancer would have gotten him anyway) the same. In the first case: self-inflicted tragedy. In the second case: who cares?

      Why not speak of it in terms of years of average years of life lost per smoker, or some other more meaningful metric?