Academic journal article Public Health Reviews; Rennes

Tobacco Control in Industrialized Nations: The Limits of Public Health Achievement

Academic journal article Public Health Reviews; Rennes

Tobacco Control in Industrialized Nations: The Limits of Public Health Achievement

Article excerpt

INTRODUCTION

In the first half of the 20th century, tobacco consumption rapidly escalated in the world's industrializing nations. Almost as quickly, with the emergence in midcentury of a scientific consensus that cigarette smoking posed a profound threat to the health of individuals and societies, there began an extraordinary movement to limit, control, and ultimately eliminate tobacco use. What started as a campaign fueled by public health advocates and resisted by private and public actors dependent upon tobacco revenues had, by century's end, triggered far-reaching social, political, and economic changes in the United States and Western Europe. Although as we shall see there are some striking differences between 1963 and 2002, the prevalence of smoking among men in the West was reduced by 50 percent; among women there were also significant if less dramatic achievements. Table 1 underscores the magnitude of the changes in France, Japan, Germany, the United Kingdom, and the US.

For much of the postwar era, the rates of smoking among Japanese men were almost twice that of other developed nations. In 1965, 83.2 percent of men smoked, and in 1997 57.6 percent were still smokers.3 Among women, there was virtually no change in that same 20-year period. More striking, the steep social gradient in terms of income and education that characterizes smoking in Western Europe and the United States was all but absent. Ten years later, in 2004, a study found virtually no change in smoking at the population level among men. When the analysis was stratified by age, however, the impact of income among those 25-39 was most obvious. Thus, although overall smoking rates remained high, "the impact of income on smoking was not much smaller than in other industrialized nations".4

What strategies and policies can account for the changes we have witnessed? Do they tell us anything about maybe the necessary to press? The public health campaign against tobacco? As industrialized nations sought to confront both an industry that manufactured a toxic product and a deeply embedded pattern of social behavior, they pursued a common set of strategies. Among the first interventions was the requirement that cigarette packages and advertisements include warning labels. But warnings alone were quickly understood to be insufficient to counteract the impact of advertising. As a result, public health advocates began to press for limits or bans on the advertising and promotion of tobacco products.5

In addition to their focus on advertising restrictions, tobacco control advocates have also pressed for price-based regulations. Tobacco has long been the object of taxation, and tobacco taxes have represented an important source of government revenue. By the 1980s, some economists began to argue that certain costs of smoking health care expenditures and lost productivity, for example represented negative externalities.6 Those costs could be internalized, they claimed, through the imposition of taxes. Such justifications would assume less importance as public health officials increasingly asserted that the purpose of taxation was the suppression of demand. The extent to which the elasticity of demand was affected by the addictive nature of nicotine was a matter of some dispute, but the fact that prices could affect consumption, particularly by adolescents and others with limited disposable income, was beyond question. Whether such taxes are unacceptably regressive in light of the social gradient that has emerged or whether the increased burden on the relatively poor can be justified by the extent to which such burdens advance the health of those compelled to pay higher prices for cigarettes, remains controversial. Finally, governments have moved to restrict smoking in public settings. Such moves often occurred before the evidence of harm to non-smokers was substantiated,7 but ultimately science provided a powerful warrant for such environmental measures. …

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