The respected international medical journal The Lancet reported this week that in spite of all we’ve learned about the devastating health consequences of smoking, the number of smokers worldwide has increased to an all-time high of 1.1 billion, and the number of tobacco-caused deaths in 2019 rose to nearly 8 million.
The comprehensive analysis of the growing global burden of tobacco-attributable disease makes sobering reading. But it is short on solutions.
That remains especially true for Alabama, where an estimated 8,600 individuals died in 2019 from smoking-caused conditions, including heart disease, emphysema, and lung cancer. (By comparison, 930 Alabamians lost their lives in motor vehicle accidents, the fifth highest number among the states.) Nationwide, nearly 500,000 Americans died from smoking that year.
Although Alabama’s adult smoking prevalence declined from 22.5% in 2007 to 20.3% in 2019, it’s the nation’s sixth highest rate, according to the Campaign for Tobacco Free Kids; the youth smoking rate of 7.1% ranks twelfth. Nationally, adult smoking prevalence has dropped from 42% in 1964 to 14%, but through population increases the number of smokers is still 34 million, with most in the lucrative 18-34-year old demographic.
The American Lung Association’s (ALA) State of Tobacco Control 2021 Report grades states on their anti-tobacco efforts. Alabama is one of six states that received straight Fs. The grades are based on progress in five categories:
· sufficient funding for tobacco prevention and cessation
· access to smoking cessation services
· a ban on flavored tobacco products
· a statewide smokefree indoor air law (Alabama is one of 11 states without one) and
· a substantial cigarette tax
Alabama’s cigarette tax of 67c per pack is the nation’s fifth lowest–and the lowest of any non-tobacco-growing state. Georgia’s tax is 37c. New York has the highest at $4.35.
According to the ALA, Alabama’s economy suffers $5.6 billion a year in direct costs due to smoking, including over $1 billion in lost workplace productivity and $1.7 billion in medical and hospital expenses.
But just like a mutating virus, the tobacco industry has adapted to legislative and regulatory attempts to hinder the sale, promotion, and use of its products.
Governments and the sin taxes that feed them are part of the problem. Cigarette taxes could be set high enough to crush the tobacco industry, but no governments want to kill the goose that lays the golden eggs. States rely on tobacco revenue for reducing budget deficits and things other than curbing smoking.
Tobacco tax increases may well cut sales to the poorest consumers (a pack-a-day smoker in Alabama now spends around $1800 a year on cigarettes), but tobacco companies are still laughing all the way to the bank. Cigarette stocks remain a healthy investment. Dividends paid by the three major tobacco companies sold on US stock exchanges–Altria, British American Tobacco, and Philip Morris International–are among the highest of any investment sector.
The 1998 Master Settlement Agreement (MSA) between the US state attorneys general and the tobacco industry, ostensibly to recover medical costs for smoking-related diseases, epitomizes government addiction to tobacco money. The states have spent just 3% on average of the annual payments to them from the industry to fight smoking–in Alabama’s case, just 1% of the tobacco industry’s payment of $115 million in 2016 was allocated to tobacco control efforts.
The tobacco Industry’s never-ending plea for “more research” has been heeded as if it were a reputable source. In 1985 US Surgeon General C. Everett Koop pointed to the huge body of evidence–more than 50,000 studies–that smoking causes death and disease. The number of published studies on smoking now exceeds 350,000. Have these additional papers, and the enormous amount of funding to produce them, led to improved health?
We have only recently begun to flatten the mortality curve of lung cancer, even though the United States Surgeon General, Alabamian Luther Terry, told us in 1964 what we needed to do. In stark contrast to the $3.9 trillion allocated by Congress to address COVID-19, no significant funding has ever been approved to fight smoking. Every president, Democrat or Republican, has kicked the can down the road on the smoking pandemic.
The tobacco industry remains the foremost obstacle to tobacco control. State-owned tobacco companies, notably the China tobacco monopoly in the world’s largest cigarette market, pose a daunting challenge to public health. The US, the United Kingdom, Japan, Korea, Switzerland, and Sweden, among other countries, also host powerful tobacco companies.
As a result, the survival of the tobacco industry has thus far trumped the recommendations by the World Health Organization for each nation to raise tobacco taxes, ban tobacco ads, pass clean indoor air laws, warn about the dangers of smoking, and help people stop smoking. The livelihoods of 100 million people worldwide are dependent on the production, distribution, or sale of tobacco products. Tobacco industry allies include supermarkets, convenience stores, advertising agencies, public relations firms, packaging and shipping companies; media corporations that covet advertising revenue; pharmaceutical manufacturers that make agricultural chemicals; arts organizations that solicit tobacco industry donations; politicians; and even academics who rely on tobacco industry grants. In contrast, no jobs in tobacco control will be lost if smoking and resultant disease increase. Public health failures engender research funding.
Forget health departments, legislatures, or academia. One of the keys to preventing tobacco-caused death and disease is the commitment of every physician, medical student, dean, hospital administrator, and all other health professionals to make tobacco use prevention, smoking cessation, and relapse prevention (subjects still barely touched on in medical education) top priorities. Another earth-shaking strategy would be for philanthropic foundations to shift significant amounts of funding from research to hard-hitting, paid, social media campaigns that indict tobacco companies, shatter myths (such as that the filter makes smoking safer), and subvert cigarette sales through brand-name satire (such as spoof pitches to light up a Benson & Heart Attack or an Emphysema Slims and Come to Cancer Country).
Dr. Alan Blum is the Gerald Leon Wallace MD Endowed Chair in Family Medicine at the University of Alabama, where he also directs the Center for the Study of Tobacco and Society (csts.ua.edu). This essay was adapted from a commentary he wrote in the May 27 issue of The Lancet.