Tobacco kills six million people annually. This staggering toll, more than all deaths from HIV/AIDS, tuberculosis and malaria combined, is predicted to rise to eight million deaths per year by 2030. Tackling this major public health problem lies far beyond the health sector.
Economic globalization has led to the restructuring of the industry into powerful transnational tobacco companies which dominate the world cigarette market. Their rapid expansion into 'emerging markets', in particular, has been achieved through foreign investment, aggressive marketing and policy influence.
For this reason the theme for this year's World No Tobacco Day of 'industry interference' is particularly apt. No history of tobacco control would be complete without an understanding of the industry’s undermining of public health policy.
Tobacco and health: The industry's use of framing
Lack of scientific evidence has never been a problem for tobacco control advocates. The deadly consequences of smoking were confirmed in 1954, and over the ensuing decades, countless studies confirmed the harms not only to smokers, but to those exposed second-hand, prenatally and even across generations. Despite this alarming weight of evidence, however, adoption of strong tobacco control policies has been painfully slow. Gains were achieved – restrictions on marketing and advertising, sales to minors, public smoking bans and warning labels were adopted in many countries. But, given the deadly nature of tobacco, why were these gains so hard fought and what can be done today to address the continued intransigence in so many countries?
The 'framing' of global health issues may offer new insights into this challenge. Frames are 'schemata of interpretation' that allow us to perceive, identify and label experiences in our lives and the world around us. Global health issues are subject to different frames – the biomedical, economic, security, human rights and development frames being most dominant. How issues are framed not only shapes the importance we give them, but how we act to address them. For example, whether HIV/AIDS is framed as a human rights or security issue influences the policy measures adopted.
Frames explain the ebb and flow of tobacco control over the last six decades. When the public became alarmed about the deadly effects of tobacco, the industry successfully shifted the focus of public policy debate. First, it argued that the economic importance of tobacco, in terms of employment, tax revenues and exports, far outweighed what was described as unclear scientific evidence. Second, the industry championed the right to smoke, and efforts to restrict personal choice were deemed an inappropriate interference. This economic and libertarian framing was underpinned by the world’s leading public relations firms.
Reframing tobacco control
Upon identifying tobacco control as a priority in 1998, the World Health Organization (WHO) Director-General Gro Harlem Brundtland recognized that overcoming longstanding neglect required more than well-rehearsed scientific evidence. The Tobacco Free Initiative (TFI) was tasked with negotiating the Framework Convention on Tobacco Control (FCTC), which proceeded to reframe tobacco control in several ways. It began by using language reminiscent of infectious disease outbreaks, describing tobacco as a 'global pandemic' with the industry as its key 'vector', to justify collective action by WHO member states. TFI then built an important alliance with the World Bank, the latter providing much respected data on the true economic costs of tobacco to societies.
Lessons for implementing the FCTC
Tobacco control has always been a battle for hearts and minds. If implementation of the FCTC is to be successful, public health advocates must win on both fronts.
Framing remains a core part of industry strategy. Amid crisis in the world economy, the industry is decrying efforts to curb its operations on trade and investment grounds, alleged infringements of intellectual property rights, and the need for 'sensible regulation'. On an individual level, tobacco control advocates have been depicted as 'killjoys' preventing people from enjoying a small pleasure during a time of economic austerity.
For the public health community, identifying messages that will gain policy traction will be more effective than calling for tobacco control on general health grounds. The majority rights of non-smokers remain an effective platform for public smoking bans. The real cost of tobacco, to struggling economies and individuals, is likely to be a powerful frame. And stronger regulation of corporations that spread disease and death worldwide should form part of broader debates about how we manage globalisation better in future. It is only by reframing the stark facts about tobacco in compelling ways that the public health community can continue to turn the tide on this deadly industry.