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BMJ No 7106 Volume 315 Editorial Saturday 23 August 1997
The challenge for Beijing: the 10th world conference on tobacco or healthThe best national strategies need to be adopted worldwideSee Editorial p 439, News p 448International tobacco control workers have cause for modest celebration. Recent events in Britain, the United States, Canada, Singapore, Hong Kong, Western Australia, and New Zealand indicate the progress that is being made in controlling the devastating effects of the transnational tobacco industry. Even so, compared with the extent of the problem, progress is slow and limited to only a few wealthy countries. The 10th world conference on tobacco or health in Beijing this month comes at a critical time. In developing regions over half the men are current smokers and cigarette consumption is rising. Already tobacco prematurely kills an estimated three million people worldwide each year and this will rise to 8.4 million deaths annually by 2020.(1) Virtually all this increase will occur in developing countries, which are most vulnerable to the tobacco industry and where tobacco control activists are rare. Most of the burden of disease in the next 30 years will fall on current smokers, indicating the importance of programmes to support cessation. Comprehensive tobacco control programmes are cost effective.(2) In Britain the antitobacco summit called last month by the minister for public health, Tessa Jowell, signalled a desire to make up for long government neglect of tobacco issues, especially the rise in smoking by children and the continued high rates of smoking by the most deprived citizens. Later this year a white paper will outline plans for a comprehensive tobacco control policy. The legislation should be inspired by the best examples around the world. It should include banning all direct and indirect advertising and the rapid phasing out of sponsorship - which can be replaced by funds raised from an increase in tobacco tax. Replacement funding agencies in New Zealand and Australia provide a good model for Britain. Since legislation in Britain will not be passed until at least 1999, the industry has time to regroup: vigorous political leadership will be required to withstand the inevitable bullying. Strong leadership from Britain may also help to ensure the passage of the stalled European Union directive on tobacco, which would compel member states to ban tobacco advertising. Progress in Britain may also be emulated in the rest of the Commonwealth and may impede the worldwide lobbying efforts of BAT and Rothmans International, two of the world's largest tobacco companies, both based in England. In the United States, however, the proposed settlement negotiated by the industry and state attorney generals is problematic. Many gains from the proposed settlement have already been achieved in other countries by legislation, and legislation has achieved much that negotiation will never do.(3) Former surgeon general Everett Koop and former commissioner of the Food and Drugs Administration David Kessler have urged Congress to reject the tobacco settlement on the grounds that the industry should be controlled by legislation, not negotiation.(4) In particular, they want the Food and Drug Administration to have explicit authority to regulate and eventually eliminate nicotine from tobacco products. The costs of the settlement will be tax deductible by companies, and other costs will probably be recouped by price rises, given the relative cheapness of American cigarettes. The endorsement of the settlement by the American stock market is strong evidence that it will not harm the industry. Furthermore, the American settlement will do nothing to prevent the emerging epidemic in developing countries: if anything it will accelerate the gobal spread of smoking. Indeed, it underscores the need for tobacco control to become a global issue, not just a national concern. New and stricter tobacco control legislation in several countries provides a model for countries contemplating legislation. Canada's new Tobacco Act, passed earlier this year, replaces the previous act, which had key sections on advertising and promotion struck down as unconstitutional by the Supreme Court in 1995. The new act has again been challenged by Canada's three major tobacco companies. In New Zealand the legal age of sale of cigarettes has been raised to 18, and point of sales advertising is being phased out. In Singapore and Western Australia bans on smoking in almost all enclosed workplaces are coming into force. However, these countries represent tiny markets for the industry. The real prize is China. With a quarter of the world's smokers, smoking a third of the world's cigarettes, China is now the major tobacco control battleground. In anticipation of this month's conference, many initiatives have already been taken in China, and new programmes may be announced at the conference.(5) Recent tobacco control legislation in Hong Kong may now provide a model for the rest of China. The conference's twin themes are developing countries and women, and a record number of delegates from developing countries will attend. The World Health Organisation will emphasise the need to support the proposed International Framework Convention for Tobacco Control: signatory states would agree to pursue broad tobacco control goals. This treaty has the potential to provide developing countries with a defence against the tobacco industry's marketing offensives.(6) The challenge for the Beijing participants is to use the energy and enthusiasm generated by the conference to extend gains in tobacco control to all countries. This requires a unified response based on the best national strategies. In particular, progressive countries and non-governmental organisations should financially support global efforts to limit international trade in tobacco products and ensure that the World Trade Organisation restricts tobacco trade on public health grounds. The conference provides a real opportunity to accelerate the trend towards a smoke free world. Robert Beaglehole Professor
Department of Community Health, References 1 Murray C J L, Lopez A D. Quantifying the burden of disease and injury attributable to ten major risk factors. In: Murray C J L, Lopez A D, eds. The global burden of disease. Cambridge: Harvard University Press, 1996. 2 Reid D. Tobacco control overview. Br Med Bull 1996;52:108-20. 3 Burns D, Benowitz N, Connolly G N, Cummings K M, Davis R M, Henningfield J E, et al. What should be the elements of any settlement with the tobacco industry? Tobacco Control 1997;6:1-4. 4 Schwartz J. To anti-tobacco advocates, issue is anything but settled. Washington Post 1997 Jul 30. 5 Mackay J. Battling upstream against the tobacco epidemic in China. Tobacco Control 1997;6:9-10. 6 Collishaw N. An international framework convention for tobacco control. Heart Beat 1996; No2:11.
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