by Allan Brandt
One of the most disturbing ironies of twentieth century public health is that it was the relative success in reducing tobacco use in the developed world that spurred the sharp increases in cigarette use in developing nations. As Western markets grew increasingly vulnerable to state regulation and a rising antitobacco movement, the multinational tobacco companies began to look covetously at new, untapped markets abroad; first in the developing world and then, following the fall of the iron curtain, in eastern Europe.11 These markets offered an opportunity to more than offset the losses (from quitting, prevention, and deaths) the industry experienced in the industrialized West.12
The dramatic fall in American consumption of cigarettes set the stage for the intensive push into new markets. Between 1975 and 1994, overall cigarette sales in the United States declined by more than 20 percent (from 607.2 to 485 billion cigarettes). During the same period, production of American cigarettes rose by 11 percent.13 As a result, the ratio of exported cigarettes rose sharply during this period, and opening new markets became a critical element in the industry’s growth. Cigarette exports from Philip Morris, R.J. Reynolds, and Brown & Williamson would more than triple between 1975 and 1994, from about 50 billion to 220 billion. This remarkable transformation in the markets for American cigarettes resulted from an opening of world commerce that included changes in world trade regulations, efforts by the companies to open new markets, and interventions on behalf of industry by the U.S. government. Buck Duke’s vision of a truly global market for the cigarette has at last been realized.14 This historical change in tobacco markets from national to transnational has profound implications for world health.15
We stand on the threshold of a global pandemic of tobacco-related diseases that is nothing short of colossal. The cigarette will cause far more deaths in this new century than in the last, irrespective of innovative and effective clinical and public health interventions in the future.16 At no moment in human history has tobacco presented such a dire and imminent risk to human health as it does today. In 2000, 12 percent of adult deaths globally—four million deaths—were associated with cigarette smoking.17 This ratio is projected to double by 2020, to nearly one quarter of all adult deaths. The largest increases will be among women: although nearly half of all adult men in the developing countries are smokers, only about 11 percent of adult women smoke.18 Each day, 80,000 to 100,000 individuals become new smokers; most of these are children and adolescents, mostly in the developing world. While tobacco-related deaths are now evenly divided between the industrialized and developing nations, this ratio will not long endure. Of the world’s 1.1 billion current smokers, 80 percent live in low- or middle-income countries, with nearly 40 percent of the total number of smokers in the world living in East Asian countries and 20 percent living in former Soviet Bloc countries. By 2030, developing nations will claim 70 percent of the world’s overall tobacco mortality, exacerbating the health disparities between the developed and the developing world.19 One hundred million Chinese men currently younger than twenty-nine will die from smoking.
Source: Judith Mackay and Michael Eriksen, The Tobacco Atlas (Geneva: World Health Organization, 2002).
CHART 7 Deaths from tobacco-related diseases in the developed and developing world, 2000 and 2030
The international commerce in tobacco is one of the great ironies of globalization. On one hand, globalization has led to the conviction that traditional barriers to trade and commerce should be reduced to encourage development and growth. Worldwide transportation and communication have led to new forms of cosmopolitan and homogenized cultures. As President Bill Clinton noted in his 2000 State of the Union address:To realize the full possibilities of this economy, we must reach beyond our own borders, to shape the revolution that is tearing down barriers and building new networks among nations and individuals, and economies and cultures: globalization. It’s the central reality of our time.20
On the other hand, globalization is seen as consolidating market economies at the expense of indigenous practices, health, and local environments. As a result, it is increasingly recognized as a rising force in shaping new patterns of disease. Shifts in trade and markets, the diffusion of new media and cultural contacts, and the migration of services, peoples, and goods are rapidly changing how individuals get sick and die.21
The global movement of cigarettes illuminates current dilemmas about trade, commerce, and equity in the new global economy. Although many industrialized nations over the last century have evolved regulatory frameworks to address the risks associated with the diffusion of consumer products and markets, such structures are rare in the developing world, and international controls are even more unusual. Even in the industrialized nations, tobacco regulation lagged far behind other forms of consumer protection. It is impossible to say whether this pattern will be repeated in the developing world; one can only note that in most of the world, the tobacco industry maintains strong corporate ties to national governments that typically have little or no history of product regulation.
No one has followed globalization more closely or better understood its implications than the tobacco companies. The industry has long been committed to the notion of the “global smoker” and “global brands.” As Philip Morris executive Hugh Cullman explained in a 1977 report to the company: “Since 1959, Philip Morris has built a substantial commitment in the developing countries. We have invested more in the developing world than we have recovered. We have been investing for the future.”22 With growing regulatory concerns in the United States and a declining ability to subvert scientific realities, the American tobacco companies moved to expand their international operations.
Source: Philip Morris Annual Reports; FTC Reports.
CHART 8 Domestic cigarette production versus Philip Morris international production
The industry secured powerful governmental support for these efforts. U.S. federal trade representatives, for example, repeating the mantra of open markets, worked assiduously through the 1970s and 1980s to expand opportunities for American tobacco companies abroad by attacking high tariffs and bans on tobacco imports.23 To industry analysts, this was a classic win-win proposition. They would gain new markets; developing countries would reap the joint rewards of culture and trade. As a tobacco industry executive explained in 1982:Demographically, the population explosion in many underdeveloped countries ensures a large potential market for cigarettes. Culturally, demand will increase with the continuing emancipation of women and the linkage in the minds of many consumers of smoking manufactured cigarettes with modernization, sophistication, wealth, and success—a connection encouraged by much of the advertising for cigarettes throughout the world. Politically, increased cigarette sales can bring benefits to the government of an underdeveloped country that are hard to resist.24
By 1984, Marlboro was China’s fourth largest advertiser. As it worked to pierce the world’s biggest cigarette market, Rene Scull, vice president of Philip Morris Asia, explained in 1985: “No discussion of the tobacco industry in the year 2000 would be complete without addressing what may be the most important feature on the landscape, the Chinese market. In every respect, China confounds the imagination.”25
Like many developing nations, China has a state-run tobacco monopoly. Begun by Duke’s British American Tobacco in the late nineteenth century, the company was nationalized by the Communists following World War II. By the mid-1990s, the China National Tobacco Company was producing some 1.7 trillion cigarettes a year (approximately one-third of the world’s total), with modest technical support for joint ventures from the multinationals eager to get a foot in this giant door. The national government gets some 12 percent of its overall revenues from cigarette sales. China is caught between the immediate financial benefits of tobacco revenues and the devastating long-term health impacts that will inevitably result from the some 350 million Chinese currently addicted.26
The rise of smoking in China, where per capita consumption of cigarettes more than doub
led between 1965 and 1990, mirrors what happened some forty years earlier in the United States. Today, the Chinese market for cigarettes is overwhelmingly male, with over 60 percent of men being regular smokers versus only 7 percent of women. Such ratios have historically been read within the industry as opportunities. Public health has a less benign outlook. According to studies conducted by the Chinese health ministry in collaboration with British epidemiologist Richard Peto, tobacco-related diseases caused more than five hundred thousand deaths in 1996; by 2025 this number would jump to two million (nearly one-third of all deaths occurring between the ages of thirty-five and sixty-nine). Peto noted that when he was invited to Beijing to explain his findings, “my message was very simple: If the Chinese smoke like Americans, they’ll die like Americans.”27
Beyond devising economic and policy strategies, tobacco companies carefully research the cultural significance of multinational products in order to learn how best to break into new markets. Often it is necessary to negotiate a shift from traditional indigenous uses of tobacco to the homogenized and modern product. Using marketing approaches like those it employed in the United States in the early twentieth century, the industry first seeks to kindle interest in cigarettes. As one executive explained in a trade journal in 1998:Globalization has its limits. In India, for instance, around 80 percent of the population uses traditional tobacco products such as bidis or chewing tobacco. . . . [But for] how long will these markets resist the attraction of global trends? In one or two generations, the sons and grandsons of today’s Indians may not want to smoke bidis or chew pan masala. . . . Global brands are one way to accelerate this process.
In India and elsewhere, where limits on public smoking and advertising are modest, tobacco companies can travel back to a time when there was little opposition to their most aggressive marketing ploys. With the explicit goal of transitioning people from indigenous smoking practices in favor of worldwide brands, the companies utilize well-worked strategies to promote consumption, including sports sponsorship, rock concerts, fashion shows, and free samples. Where regulatory mechanisms exist, the tobacco companies have found them relatively easy to subvert. Empty cigarette packages offer free admission to discos. In Malaysia, R.J. Reynolds employs “brand stretching” to turn Salem Power Station into a prominent record store. In Vietnam, where ads are prohibited, the red and white Marlboro chevron appears widely. The use of tobacco brands in these related contexts “has no relation to cigarettes, absolutely,” an R.J. Reynolds spokesman explained. “It was a trademark diversification program.”28 The tobacco companies bring a century of marketing savvy, intelligence, and doublespeak to their promotional efforts in these developing nations.29
Just at the moment that the cigarette was losing its glamour, sophistication, and sexual allure in the West, the companies sought to recreate these connotations of smoking in developing countries. Marketing News exclaimed in 1991: “Western models and lifestyles create glamorous standards to emulate, and Asian smokers can’t get enough.”30 Western brands, in particular, came to be viewed as a mark of social status, cosmopolitanism, and affluence. Western cigarettes offered smokers new social prominence. Such meanings are not inherent in cigarettes; they are explicitly constructed by promotion and marketing. It was an irony not lost on multinational tobacco companies that even as they resisted regulatory initiatives as paternalistic and imperialistic, they aggressively promoted Western cultural idioms. Their campaigns to bring cigarettes to new peoples and places met with considerable success. The industry celebrated the identification of these new markets. As Burson-Marsteller, a Philip Morris public relations firm, explained:In any event, despite the lingering tobacco liability cases and the drop in cigarette consumption in the United States, the tobacco companies themselves have never been healthier. First, foreign consumption of American cigarettes continues to grow dramatically, because of the falling value of the dollar, a reduction in tariff and non-tariff barriers to cigarettes and the image of American cigarettes as the best in terms of quality and character. Japan is now importing U.S. cigarettes, and China shows great potential.31
As one journalist noted, “Americanization” has become a well-recognized social process worldwide:Even in countries where the American government is disliked, there is a reverence for American things. . . . I came upon 17-year-old Daniel Fuqs, who was leaning against an iron fence. . . . He was wearing Levi’s and loosely laced Nikes, and smoking a Marlboro: “We like American cigarettes, American music, American clothing. The poorer Brazilian kids can’t afford Nikes or Reeboks, so instead they buy baseball caps with the names of American teams. Anything to tie yourself to America. We resent American imperialism, but there is no other way.32
American advertising icons are found everywhere. “The red-and-white Marlboro chevron is as familiar as Coca-Cola signs in nations with large numbers of smokers, like the Philippines, where the entire city of Manila smells like an all-night poker game.”33
A critical aspect of market development in non-Western nations involves creating interest among women and children in smoking. As Gregory Connolly, former head of the Massachusetts Tobacco Control Program, noted, “When the multinational companies penetrate a new country, they not only sell U.S. cigarettes but they transform the entire market. . . . [T]hey transform how tobacco is presented, how it’s advertised, how it’s promoted. And the result is the creation of new demand, especially among women and young people.”34 In many cultures, tobacco use, including cigarette smoking, has traditionally been a male behavior. The spread of smoking among both sexes in the United States required deep changes in attitudes about gender equality as well as a steadfast effort by the cigarette industry to erase any differences in social convention. Overcoming social mores against women smoking marked a central element of establishing the salience of the cigarette. But as the prevalence of smoking among women approached that among men, so did the prevalence of the resulting diseases. In the United States, for example, rates of lung cancer eclipsed breast cancer in the mid-1980s, following the major increases in women smokers in the middle years of the twentieth century.35
As it looks to the developing world, the multinational tobacco industry consciously seeks to recreate its history in the West by aggressively marketing the association of cigarette smoking with modernity and gender equality. In once again making smoking a symbol of women’s rights, the industry had taken a powerful, if outdated, set of meanings for its product and deployed it in a new global context.36 The association of cigarette use with independence and modernity has proved very effective in recruiting women smokers, especially in countries where little public information is available about the health risks of smoking. The tobacco companies have also attracted women smokers—girls, actually—with specific women’s brands, light blends, and plenty of free samples. These strategies, refined through decades of test-marketing in the West, are now reengineered to suit new populations.37 Further, the industry has placed antitobacco advocates in the position of seeming to resist equal status for women because they support maintaining restrictions on women smoking. Serving women’s health has been made to appear as if it opposes their freedom.38
The other crucial component of building a market is the appeal to youth. American and other multinational companies have used popular music, discos, and nightclubs to turn Western cigarette brands into status symbols among teenagers. Smoking is promoted at discos and nightclubs, on clothing and “gear,” all linking brands to youth culture. Marlboro T-shirts in children’s sizes may be found in Kiev and Kenya.39 Not coincidentally, smoking starts at younger and younger ages worldwide. According to the WHO, 250 million children alive today will ultimately die of smoking-related diseases.
In the United Nations Convention on the Rights of the Child, which came into force in 1990, it was determined that:[s]tates have a duty to take all necessary legislative and regulatory measures to protect children from tobacco and ensure that the interests of children take precedence over those of the tob
acco industry.
But children are not only at risk to become smokers; they are also vulnerable to the smoke exhaled by adults. Because a single adult smoker in a household exposes all the children living there, a majority of the world’s children have significant exposure to environmental tobacco smoke. The World Health Organization (WHO) estimates that worldwide some 700 million children live in homes with regular adult smokers.40 Any assessment of the global impact of tobacco use must include not only the enormous health effects on smokers, but the now well-documented consequences for nonsmokers as well.41
As the risks of tobacco were better understood and regulated in the West, multinationals began to target nations where regulations were weaker. The laws tended to be especially weak in nations that were significantly dependent on tobacco revenues and those with less stable governments. Even countries that have tried to restrict tobacco sales have been frustrated by the combination of emerging free-trade agreements and the companies’ aggressive efforts to expand into new markets. And the companies have brought to the developing world their long experience in turning regulation on its head. From its century-long experience in Western nations, the industry knew that aggressive marketing of tobacco prior to any regulatory intervention assured important market opportunities that, given the addictive qualities of the product, would be difficult to reverse once initiated. It became crucial to the industry to gain a foothold in expanding markets before control efforts could get organized. Moreover, in societies where infectious disease and violent trauma remain significant causes of death, the risks of smoking could be portrayed as small and distant. Indeed, it took an era of sustained good health in the West to fully expose the long-term harms of cigarette smoking.