The global epidemic of tobacco use kills more people annually than malaria, tuberculosis and Aids combined. Increasingly, the people affected by tobacco live in developing countries. Though tobacco use is not an infectious epidemic, it has a lot in common with contagious illnesses – we know how to prevent the spread of the disease (effective measures that discouraging smoking) and yet the disease continues to evolve (tobacco corporations adopt new strategies to make smoking attractive). Like a mutating parasite, tobacco companies respond to public health efforts by exploiting weaknesses and compromising the global response. It is a big problem that requires bigger action.

If tobacco corporations stopped resisting public health efforts, we could end tobacco use in a generation with a range of well-known, widely endorsed and effective measures. The World Health Organisation’s (WHO) Mpower summarises the six basic measures for reducing smoking: monitoring tobacco use; protecting people from smoke in public places; offering help for smokers to quit; warning about the dangers; enforcing bans on advertising; and raising taxes. These measures have reduced smoking and associated deaths in the countries that have adopted them, and more countries are following suit. Some of the biggest advances against tobacco in recent years have occurred in middle-income countries.

Brazil reduced smoking rates by 50% over a 20-year period (1980–2010) using the Mpower measures. It increased tobacco taxes, implemented a smoking ban in all enclosed public places and workplaces, required labels to have graphic warnings covering at least 65% of the pack and provided services to help people quit.

In 1992, Thailand passed two laws to curb tobacco use: the Tobacco Product Control Act – banning tobacco advertisement and sales to minors – and the Non-Smoker Health Protection Act – prohibiting smoking in public places. Subsequently, tobacco use among adults has fallen from 32% to 21%. The government has continued to strengthen these tobacco control efforts by restricting advertisements at point-of-sale and increasing the coverage of graphic warnings on packages. Thailand has a particularly compelling anti-smoking advertisement in which young children ask adult smokers for a cigarette. Advertising like this is extremely effective at helping smokers make the cognitive changes needed to quit.

Unlike parasites, tobacco use does not mutate by itself. Rather, it requires tobacco companies to actively devise strategies and oppose public health measures that save lives. Strategies include lobbying against tobacco control measures, suing countries who take action and designing new products that confound regulations.

In Uganda, curbing tobacco consumption has been an uphill battle against lobbying by the tobacco industry. Ugandan tobacco control legislation failed in 2011 due to industry opposition. In response, tobacco control advocates organised themselves to respond more effectively. In 2013, when tobacco companies lobbied to reduce a proposed tobacco tax, the tobacco industry monitoring team was able to support parliamentarians with information that ultimately succeeded at getting the higher tax enacted.

International action is needed to counteract this bullying by big tobacco. For example, Philip Morris International is now suing Uruguay in a World Bank tribunal with claims that mandatory warnings on packages devalued its trademark. Philip Morris has deep pockets to take on Uruguay. Fortunately, the Bloomberg Foundation agreed to cover the costs of defending Uruguay. Without this money Uruguay admitted it would have had to retract its tobacco control law and settle with Philip Morris out of court.

The latest evolution of tobacco company strategies involves new nicotine products that make smoking attractive and confound the boundary between toxic and less toxic uses. The WHO’s recent report on electronic nicotine delivery systems, sold as “e-cigarettes”, refutes health and safety claims that are made for these products and alerts countries to the risks that tobacco companies may bypass advertising restrictions on conventional cigarettes and renormalise smoking.

The public health community has an important role to play in demonstrating the magnitude of tobacco’s threat to public health and calling on governments to strip away the trademark protections, rights to sue and opportunities to lobby that big tobacco uses to bully public representatives. Just helping governments see that these measures are cost-effective can build political support.

Until then, the best approaches will have to be continued implementation of the Mpower approaches, close surveillance of the industry’s mutating strategies, more transparency in government and draining the trade law loopholes in which they thrive.

William Savedoff is a senior fellow at the Center for Global Development. Follow @billsavedoff on Twitter.

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