Unless urgent action is taken, tobacco will kill 1 billion people in the 20th Century. We can end the epidemic of tobacco-caused disability and death.
Tobacco has replaced tuberculosis as "Captain of all these men of death." Unlike infectious disease threats, the vector that spreads tobacco is a business – the tobacco industry. Tobacco continues to kill more than half a million people in the U.S. every year, and more than 8 million people every year around the world.
As Health Commissioner in New York City, I made tobacco control my top priority. We raised the tax on tobacco, made public places smoke-free, ran hard-hitting anti-tobacco ads, supported smokers to quit, and more. And, after a decade in which there were no decreases in use, we made progress, as this article and others and the figure below show. We used data to drive and direct progress. One of the most challenging initiatives was the smoke-free air law*; smoke-free laws now cover more than billion people around the world.
Progress reducing tobacco use in New York City
In an early media interview, I commented that for a decade my enemy had been a microbe, the tuberculosis bacillus, but that now it was a really low life form, the tobacco executive.
It was a good line, but problematic. I received a letter from the Phillip Morris company, which was then headquartered in New York City. (They later moved out, citing the smokefree workplace law.)
The letter from Phillip Morris noted that describing people as a low life form was a type of hate speech. I had to admit that they were right. So, from then on, I referred to tobacco executives in objective terms: as mass murderers.
One of the challenges to tobacco control – in addition to the tobacco industry vector and the addictiveness of nicotine – is a set of myths.
- 1.MYTH #1: PEOPLE HAVE FREE CHOICE WHETHER OR NOT TO SMOKEWe all like to think we are creatures of complete free will. However, free will in the case of tobacco is subverted by advertising and addiction. More than 80% of all regular smokers began smoking by the time they were 18 years old. Most smokers want to quit.26 However, the tobacco industry ensures that there is enough nicotine in every cigarette to keep people addicted, and productionmethods and chemical additives increase nicotine delivery.
- 2.MYTH #2: EVERYONE KNOWS HOW BAD SMOKING ISMost people are generally aware that smoking is not healthy, but instances of poor knowledge about the health risks abound. Relatively few women are aware of gender-specific health risks, including cervical cancer, osteoporosis, early menopause, miscarriage, ectopic pregnancy, and infertility. Fewer than half of Canadian adults aged 55 to 74 years identified smoking as a major cause of heart disease. Cigarettes cause disease in nearly every organ of the body.
- 3.MYTH #3: JUST A FEW CIGARETTES A DAY CAN’T HURT The risk of cardiovascular disease becomes evident with the consumption of 3 to 5 cigarettes a day. Cardiovascular disease may be caused by exposure to carbon monoxide and other combustion products, which suggests that any “reduced risk” tobacco product that is ignited and inhaled is unlikely to significantly decrease tobacco-related illness and death from cardiovascular causes.
- 4.MYTH #4: “LIGHT” CIGARETTES ARE LESS HARMFUL Despite decades of the tobacco industry marketing light cigarettes that are purported to have lower tar and nicotine content, there is no meaningful difference in smoke exposure or health risks among cigarettes with different tar and nicotine yields. Many low-tar, light, or ultra-light cigarette smokers unconsciously compensate for artificially reduced machine-measured tar and nicotine levels by smoking more cigarettes, inhaling smoke harder and deeper into the lungs, and blocking filter ventilation holes to increase the concentration of inhaled smoke. The tobacco industry has been aware of this compensation by smokers for at least the last 4 decades.
- 5.MYTH #5: IT’S EASY TO STOP SMOKING; IF PEOPLE WANT TO QUIT, THEY WILL The tobacco industry has admitted privately that tobacco has an addictive potential similar to opium. Nicotine may be comparable to heroin, cocaine, and alcohol in addiction potential. Most smokers want to quit and make at least 1 quit attempt each year.
- 6.MYTH #6: CESSATION MEDICATIONS DON’T WORK Medications greatly increase the likelihood smokers will quit. Ideally, every smoker would be counseled to quit at every clinical encounter, and every smoker who wants to quit should be provided medications, free of charge, to increase their chance of success.
- 7.MYTH #7: ONCE A SMOKER, ALWAYS A SMOKER Most Americans who have ever smoked have already quit, and anyone can quit.
- 8.MYTH #8: SMOKERS MAY DIE EARLIER, BUT ALL THEY LOSE ARE A COUPLE OF BAD YEARS AT THE END OF LIFE . The average smoker who dies from tobacco-related causes loses about 14 years of life. Among nonsmokers, 95% of that additional time will be spent without disability. Not smoking extends life, including disability-free life, and compresses disability into a shorter period of time. Elderly smokers have the physical health expected of people 2 to 4 years older and the mental health expected of people 10 years older than their actual age. Smoking increases the risk that an older person will lose his or her independence, and it reduces the chance of regaining autonomy. It is never too late to quit—even people who quit after decades of smoking improve their health and their life expectancy.
- 9.MYTH #9: SECOND-HAND SMOKE MAY BE A NUISANCE, BUT IT ISN’T DEADLY Second-hand smoke causes illness, disability, problems for infants exposed in utero – it kills.
- 10.MYTH #10: TOBACCO IS GOOD FOR THE ECONOMY The tobacco industry argues that tobacco creates employment, raises tax revenues, and contributes to the gross domestic product. However, the societal costs of tobacco use far outweigh any economic benefits. The World Bank concluded that money not spent on cigarettes would instead be spent on other goods and services that in turn would generate other jobs and economic activity to replace any that would be lost from the tobacco industry. In the United States, completely eliminating tobacco from the economy would result in an estimated net increase of more than 130 000 jobs nationwide.
- 11.MYTH #11: WE’VE ALREADY SOLVED THE TOBACCO PROBLEM Despite declining smoking prevalence, there are more than a billion smokers in the world and tobacco remains the leading cause of death in the U.S. and globally. Although there are many important health issues that also demand attention, in tobacco control is that we have proven interventions. Higher taxes, expansion of smoke-free environments, increased use of cessation treatments, public education, and more have all been proven to decrease tobacco use.
- 12.MYTH #12: THE TOBACCO INDUSTRY NO LONGER MARKETS TO KIDS OR UNDERMINES PUBLIC HEALTH EFFORTS The tobacco industry remains the leading cause of tobacco use globally, continues to try to undermine public health control measures, and actively promotes use in kids to replace their dying customers.
In 2005, Mayor Mike Bloomberg asked me to help him develop his global health philanthropy. Working on nights, weekends, and vacations (with approval to do this pro bono from the NYC Conflict of Interest Board), we developed the Bloomberg Initiative to Reduce Tobacco Use, and announced it in an article in The Lancet in 2007: How to prevent 100 million deaths from tobacco. The calculation actually added up to 158 million (table below), but we wanted to underpromise and overdeliver. In the more than a decade since, Mike Bloomberg has donated more than $1 billion to tobacco control programs in countries around the world, with more than 35 million lives saved so far.
Frieden TR, Bloomberg MR. How to prevent 100 million deaths from tobacco. Lancet 2007;369:1758-61.
In just 5 countries, new policies and programs resulted in a reduction of the number of smokers by more than 30 million
Tobacco control policies and programs succeed in helping smokers quit and protecting their families
The World Health Organization summarizes the status of tobacco control in periodic reports. As of 2013, there was some but not nearly enough progress, as I summarized* in the table below.
Status of tobacco control in 2013
In their most 2019 report, WHO noted that the number of people protected by at least one effective tobacco control measure had quadrupled since 2007. Although there has been good progress, much more progress is needed, particularly to increase tobacco taxation – the single most effective intervention. The table below shows how much further the world has to go to stop the tobacco epidemic.
WHO Report on Tobacco Control, 2019
Reprints. Articles marked with * are available by request (all others are open source and available through the links). To request a reprint: