The global grip of cigarette smoking

An Indian man smokes a cigarette on "World No Tobacco Day" in Mumbai.

Fifty years ago this month, U.S. Surgeon General Luther Terry announced the bombshell conclusions of a new report to a crowded room of journalists: Cigarette smoking causes lung cancer, is associated with other deadly illnesses and warrants remedial action.

That 1964 surgeon general’s report on smoking and health spurred profound and lasting changes in tobacco use and policies in the United States, but its call to action has gone unfulfilled internationally. In the intervening decades, smoking has expanded in developing countries and has had devastating consequences for the world’s poor.

Until that 1964 report, smoking rates had been climbing in the United States for six decades. A majority of American adults, including Terry and five of the report’s advisory committee members, were current or former smokers. Public health efforts had been bogged down in debates with cigarette industry-funded scientists over the meaning of “causality” and the relevance to humans of cancer in tobacco-exposed mice.


But, based on a review of 7,000 health studies involving more than 1 million men and women, the surgeon general report’s showed an ironclad link between smoking and lung cancer, and everything changed.

Step by step, the government cracked down on tobacco. Warning labels were added to cigarette packages (1965), cigarette advertising was banned on television and radio (1971), smoking on commercial airline flights was forbidden (1987), and tobacco products were put under Food and Drug Administration oversight (2009). U.S. cities and states — New York City and California in particular — led the way with bans on smoking in public places. U.S. criminal and civil tobacco lawsuits exposed and punished tobacco companies for decades of obfuscation and malfeasance.

The results speak for themselves. The percentage of Americans who smoke has dropped by more than half since 1964, to 18%. An analysis in a recent Journal of the American Medical Assn. estimated that the decline in U.S. smoking saved 8 million lives and extended average U.S. life expectancy by two years. Other developed countries have achieved similarly dramatic smoking reductions. A recent Citigroup investment report speculated that smoking could virtually disappear in wealthy countries over the next 30 to 50 years.

But this is not the end of the story, sadly. With sales diminishing in the United States and other high-income nations, the tobacco industry has aggressively expanded in poorer countries. Between 1970 and 2000, cigarette consumption tripled in developing nations. There are now 1 billion smokers globally, almost one-third of the world’s adult population, and smoking rates are increasing in some countries, such as Bangladesh and Indonesia. Many expect Africa to be next. Nearly 40% of the world’s children — 700 million — breathe secondhand tobacco smoke at home.

Unless urgent action is taken, the World Health Organization estimates, tobacco use will kill 1 billion people this century. More than 80% of those deaths will be in developing countries.

U.S. engagement on global tobacco control has been limited. The United States helps monitor smoking internationally, provides technical assistance when asked on tobacco regulation, and lends its financial support to WHO, some of which spills over into global tobacco control efforts. U.S. officials no longer use trade measures to pry open emerging economies to imported cigarettes, as had been done throughout the 1980s and 1990s, and, despite occasional, significant congressional pressure, have also refrained from trade disputes against other countries’ tobacco control measures.

On the other hand, tobacco use, which annually kills more people worldwide than HIV/AIDS, tuberculosis and malaria combined, is not even a line item in the $8 billion U.S. global health budget. The U.S. Agency for International Development has a formal tobacco policy, last reissued in 2009, that indicates that the agency will not undertake international tobacco control programs for staffing and budget reasons, although it will participate in international policy discussions. Nearly every U.S. trade and investment agreement negotiated over the last decade has reduced tobacco tariffs and continued to protect tobacco investments like those of any other U.S. industry. The United States is one of a handful of countries, along with Cuba, Somalia and Zimbabwe, that has yet to ratify the WHO Framework Convention on Tobacco Control.

We can do better, at little cost. The mandate and resources of federal agencies should be increased to help developing countries build their own programs to tax and regulate tobacco, and to warn against smoking. Modest aid would go a long way; ultimately, those programs would generate sufficient revenues to be self-supporting.

Finally, the United States should exempt nondiscriminatory tobacco control measures from legal challenge under its future trade and investment agreements. In recent years, multinational cigarette companies have used or threatened legal action to bully and block countries such as Namibia and Uruguay from implementing the same tobacco regulations that exist in the United States.

In 1997, Sen. John McCain (R-Ariz.) asked a question on the floor of the Senate about U.S. tobacco policy: “We want to stop American kids from smoking; so why don’t we seem to care as much about Asian or African kids?”

Seventeen years later — and 50 years since the landmark surgeon general’s report on smoking’s evils — we are still asking.

Thomas J. Bollyky is the senior fellow for global health, economics and development at the Council on Foreign Relations.