Voir page 908 le resume en francais. En la pagina 909 figura un resumen en espanol.
Who decides health policy?
Tobacco is a major health hazard and an important economic commodity. If it were not harmful to health there would be no reason to control its use. On the other hand, if the market for tobacco were small there would be little opposition to the regulation of this trade. As a result of the conflict of interest between health and corporate wealth, public policy on tobacco has evolved in an ad hoc fashion. It has emerged as a product of different pressures, including those of the tobacco industry and the public health lobby.
The tobacco industry has a formidable record of resistance to legislation and of developing new markets for its products. Even as its key markets in high-income countries were shrinking it succeeded in increasing sales in middle-income and low-income countries. As was noted in a South African newspaper: "It is an unpalatable fact that growth in this industry will take place where governments are least hostile and where populations are least educated about the harmful effects of smoking" (1).
Four cigarette manufacturers dominate about three-quarters of the global market: Philip Morris, British American Tobacco (BAT) and Japan Tobacco are transnational companies; the China National Tobacco Corporation is a monopoly, producing about 30% of the world's cigarettes but mainly supplying its domestic market (2). China is, however, preparing to become a major exporter of tobacco.
The future of the tobacco industry lies in the world's developing countries. Between 1986 and 1996, cigarette exports from the United States grew by 260%. Philip Morris now makes more profit selling cigarettes abroad than in the United States (3). BAT sells about 70% of its cigarettes in Africa, Asia, Latin America, and Eastern Europe. A BAT booklet notes: "The 1990s have seen new opportunities for the Group, especially in Central and Eastern Europe and in the Far East, with the opening up of markets previously closed to Western tobacco manufacturers". BAT has acquired factories in Hungary (1992), Ukraine (1993), the Russian Federation (1994), Uzbekistan (1994), Poland (1995), and the Czech Republic (1995) (4).
Questioned about the ethics of targeting the world's poor, a manager at Rothmans Export Ltd (now part of BAT) replied: "It would be stupid to ignore a growing market. I can't answer the moral dilemma. We are in the business of pleasing our shareholders" (5). This narrow corporate philosophy, involving an exclusive commitment to shareholders rather than accountability to all stakeholders, including customers, means that anything is acceptable in defence of company profits.
The tobacco industry has one aim: to sell the maximum number of cigarettes. In order to achieve this it is prepared to crush any obstacle. The manufacturers have ignored the harm caused by cigarettes and for decades they have engaged in a vigorous effort to silence critics, distort science, influence public opinion, control public policy and coordinate their strategy on litigation.
An insight into their behaviour is provided by the millions of pages of formerly secret internal documents that have been made public because of litigation. These documents, which are available on the Internet, take one into the boardrooms of the United States tobacco companies and their coordinating centre, the Tobacco Institute.
In the early 1950s the United States tobacco industry found itself besieged by concerns about the safety of its products as a result of new medical evidence conclusively linking smoking and cancer (6). Increasing concern in the media and the scientific community about the role of cigarettes in causing disease had reduced consumer confidence. A decline in sales combined with the threat of litigation from ailing smokers led to what was referred to in industry documents as the "1954 emergency". …