tobacco: public perceptions and the role of the industry

2003 Royal Statistical Society 0964–1998/03/166233

J. R. Statist. Soc. A (2003)166, Part 2, pp. 233–239

Tobacco: public perceptions and the roleof the industry

David Simpson and Sue Lee

International Agency on Tobacco and Health, London, UK

[Received April 2002. Revised December 2002]

Summary. The paper briefly examines the substantial risks of smoking, and how people’s per-ception of them may be influenced by tobacco control policy and by the activities of the tobaccoindustry. The comparative lack of effectiveness of the self-regulation system of implementingtobacco control policy is noted, illustrated by the example of cigarette pack health warnings,from the first examples under the voluntary system to the significantly more robust and effectivepictorial warnings system pioneered by Canada and implemented by legislation, similar to mea-sures recently approved by the European Union. Other aspects of tobacco control policy arediscussed, including health education, restricting the promotion of tobacco and changing thesocial acceptability of smoking. Three areas of success in the UK—taxation, the leadership ofdoctors and sustained media advocacy—are described; and the paper concludes by looking atprospects for the future, with the forthcoming ban on most forms of tobacco promotion and thechallenge of responding to growing demands to protect non-smokers from exposure to otherpeople’s tobacco smoke in the workplace and in public places.

Keywords: Public perception; Smoking risks; Tobacco control policy; Tobacco industry

1. Nature and scale of the risks of smoking

The substantial risks of smoking have been known for over 50 years. Scientific evidence has beenaccumulating since the late 1940s, with new additions still being made to the list of diseases thatsmoking has been shown to cause. The public’s perception of the risks has increased over timeto a current situation where most people in countries such as the UK, where public educationabout tobacco has been widespread over many years, at least know that tobacco is a seriousrisk to health. However, many people seriously underestimate the magnitude of the health risksof smoking compared with those of other dangerous activities (Lader and Meltzer, 2002). Thispaper outlines the risks of smoking and discusses factors that affect people’s understanding ofthem and the policies that can contribute to a fuller understanding, a reduction in consumptionand hence, in due course, a reduction in tobacco-related disease.The risks of tobacco use, especially cigarette smoking, are exacerbated by several crucial dif-

ferences compared with most other serious risks. First, unlike certain other common causes ofdeath or disease whose danger is due to either excessive consumption or abuse, cigarettes aredangerous simplywhenused as intendedby themanufacturers, at normal levels of consumption.Second, cigarette smoking is addictive to many smokers, making it difficult to stop smokingeven if the risks are perceived as unacceptable. Third, one of the world’s largest and wealthiestindustries is trying to increase the consumption of cigarettes as much and as fast as possible.

Address for correspondence: David Simpson, International Agency on Tobacco and Health, Tavistock House,Tavistock Place, London, WC1H 9LG, UK.E-mail: [email protected]

234 D. Simpson and S. Lee

As part of this strategy, the tobacco industry is actively working to distort the public’s percep-tion of the risks of smoking (World Health Organization Committee of Experts on TobaccoIndustry Documents, 1999) to mitigate the adverse effect on its sales and profits that is posedby greater public knowledge of the risks.Most people in the industrializedworld now know that smoking causes cancer of the lung and

certain other sites, and chest and heart disease, but the list of diseases and other health problemscaused by tobacco is extensive and still growing. According to the World Health Organization,smoking is the known or probable cause of 25 fatal diseases. The World Health Organiza-tion estimates that smoking will have caused about 62 million deaths between 1950 and 2000 indeveloped countries (WorldHealthOrganization, 1998, 1999). In populations aged 35–69 years,where smoking has been widespread for several decades, approximately 90% of mortality fromlung cancer, 15–20% from other cancers, 75% from emphysema and 25% from cardiovasculardiseases are attributable to tobacco.Tobacco causes a total of around 4 million premature deaths each year (World Bank, 1999),

about half of them in developing countries (World Health Organization, 1999; World Bank,1999). However, even though smoking rates have peaked in many industrialized countries, witha consequent fall or projected future fall in the incidence of associated diseases, the uptakeof smoking has continued to rise in the developing world, encouraged by massive promotionalcampaigns to populations amongwhom there is usually a far lower awareness of the health risksthan in the wealthier countries. The global epidemic of smoking-induced disease is therefore farfrom receding. On present trends, by 2030 tobacco will cause over 10 million premature deathsper year, about two-thirds of them in developing countries, about 1 in 6 of all adult deathsworldwide (World Health Organization, 1999; World Bank, 1999).In the UK, among teenagers who start to smoke and continue smoking for the rest of their

lives, about 50% are likely to be killed by tobacco (Peto, 1994). To put this risk into perspec-tive, Professor Sir Richard Peto has calculated the risks of dying from various causes for 100020-year-olds who smoke, if they do not give up: on average, about one will be murdered andsix will die in motor vehicle accidents (often perceived as the greatest risk of premature deathin the UK), but about 250 will be killed by smoking in middle age (before 65 years of age). Inaddition, a further 250 or so will die prematurely as a result of their smoking in old age (Petoet al., 1994).

2. Tobacco control policy

Most components of tobacco control policy have the potential to affect the perception of risk,and it is the prime objective of health warnings on cigarette packs and advertisements, and ofpublic education programmes. Advertising and other forms of tobacco promotion counteracthealth information and have a negative effect on people’s understanding of the risks. The ubiqui-tous association of cigarettes with attractive images and positive concepts undermines the truthabout their unique and substantial risks. The tobacco companies’ efforts to thwart effectivetobacco control measures, to mitigate their potential effects on sales, constitute a major factorcontributing to the relative lack of public understanding about the risks of smoking.Tobacco industry tactics to influence the public’s perception of the risks of tobacco may be

seen in some of the earliest examples of Government health policy on tobacco. From the outset,the tobacco industry denied the scientific evidence about smoking and disease or portrayedit as just one side of a complex scientific debate, or ‘controversy’, to use the favoured termin the industry. This response remained constant for over four decades. The industry has spentsubstantial sums, through public relations and lobbying activities, advertising and sponsorship,

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to play down or deny the dangers of smoking, to counter the effect of health education andto prevent the implementation of health policies that could reduce consumption. In addition,formerly confidential internal industry documents now in the public domain reveal that by the1980s deliberate dilution of the scientific literature with misleading and even fraudulent datawere commonplace (Glantz et al., 1996).

3. Self-regulation

When reliable scientific evidence of the substantial risks of smoking first emerged, Governmentsin some countries, notably the UK and the USA, attempted to address the issue. Among othermeasures, various public education activities were undertaken and, later, health warnings wereintroduced on cigarette packs. In addition, information about tobacco and disease was carriedperiodically in the news media. In response to the Government’s decision to take action, thetobacco industry persuaded many Governments, including successive administrations in theUK, that self-regulation by ‘voluntary agreements’ between the Government and the tobaccoindustry was the best method to achieve stated Government aims.Unfortunately, these self-regulation, voluntary agreements proved much less effective than

the Government had hoped, because the tobacco companies tended only to concede restric-tions if they could circumvent them and suffered no penalties for breaching them in spirit oreven in the letter. The most obvious examples concern restrictions to ban advertisements as-sociating cigarettes with sporting success, which were circumvented by sports sponsorship bycigarette brands. Such sponsorship allowed the manufacturers to continue directly advertisingtheir brands with sporting associations, under the guise that they were advertising sportingevents. In addition, it also generated substantial media exposure for cigarette brands in contextswhere they were linked to sport, such as sports reports, programme announcements and othermedia coverage.Another feature of the voluntary agreement system that was damaging to health policy was

the fact that it tended to realign Government policy away from goals which promoted healthobjectives, towards those which were consistent with continuing and increasing tobacco sales,such as the encouragement of lower emission products, at the expense of more stringent restric-tions on promotion. Most importantly, as its part of the agreements, the Department of Healthundertook not to take further action for a certain period. At best, it became an observer in asystem that was largely steered by the tobacco industry.

4. Pack health warnings

When health warnings were introduced in the UK in 1971, the wording had to be agreed by thetobacco industry, as the Government had accepted the industry’s offer of implementing policyby voluntary agreement. In the light of later experience, it seems likely that not just the strat-egy for implementing health policy on tobacco, but also much of the detail, was drafted andargued through by the industry. The first cigarette pack health warning was a small message onone side of the pack, prefaced with an attribution to the Government and entirely in capitals(both known to reduce the impact of the message being conveyed), in a small size, and in fountsthat were comparatively difficult to read (Health Education Authority, 1990). The result,

WARNING BY H.M. GOVERNMENT: SMOKING CAN DAMAGE YOUR HEALTH,

strongly contrasts with the style of the messages that are applied to products by manufacturerswho want to engage the attention of consumers, and with modern health warnings imposed by


legislation by Governments that have stood up to the industry and applied measures based onresearch into effectiveness. In addition to the flaws noted above, the use of conditional wordssuch as ‘can’ and ‘may’ can significantly reduce the effect of the warning (Linthwaite, 1985);and the rules prescribed that the colour of the print and background of the warning wereto be drawn from colours already appearing on the pack, allowing the manufacturers to usepoorly contrasting combinations to devalue the effect further (Health Education Authority,1990).In the UK, as in the USA, the tobacco industry’s hand in negotiating the health warnings

ensured that the warnings provided a potential defence in any future litigation, while failing as apublic health strategy to communicate the risks of smoking to consumers adequately (Krugmanet al., 1999). The warnings, together with the growth of cigarette sports sponsorship, culturalsponsorship and ‘brand stretching’ (the promotion of non-tobacco products using cigarettebrand names, colours and logos) illustrate how the tobacco industry managed to mitigate theeffectiveness of the voluntary agreement system to curb promotion and to help to inform peopleof the risks of smoking. Around the world, the use of more hard-hitting terms and colloquiallanguage in health warnings, such as ‘Smoking kills’ or ‘Smoking causes cancer’, which areknown to be more effective for conveying risks to smokers (Fischer et al., 1993), has beenpossible only by means of legislation. Countries in northern Europe were among the leadersin developing more effective warnings, with Sweden, Norway and Iceland using graphics inaddition to text for the past two decades. Other countries have also resisted industry pressuresand adopted tougher warnings, mostly in the industrialized world (Canada and Australia beingworld leaders) and, in amajor achievement for a developing country, SouthAfrica now requirestough warnings at the top of the front of the pack (Borland, 1997; Campaign for Tobacco-FreeKids, 2000).Since June 2001, Canada has implemented the most complex and potentially the most effec-

tive warnings in the world. Tobacco companies are required to print one of 16 health warningsin French and English on the top 50% of their packages, with bold pictures and informationdepicting some of the consequences to health of the use of tobacco, in rotation to ensure that allthewarnings appear equally on smokers’ cigarette packs over time.Onewarning says ‘Cigarettesare highly addictive’, while another states ‘Tobacco use can make you impotent’. A differentset of 16 longer messages appears on a leaflet inside the pack, also in rotation, to give furtherinformation to consumers about smoking and disease (Canadian Cancer Society, 2001).The tobacco industry mounted a vigorous campaign to try to prevent the Canadian Govern-

ment from implementing the new warnings. Public health professionals who are familiar withtobacco control issues believe that this pressure was itself an indicator of the likely effectivenessof the warnings, especially bearing in mind tobacco companies’ comprehensive research on fac-tors that are likely to affect the sales of their brands (Canadian Cancer Society, 2001). Recently,a Canadian Cancer Society survey revealed that the warnings are indeed highly effective forimproving public awareness of the serious health risk that is associated with the use of tobacco,and for encouraging those who want to stop smoking (Canadian Cancer Society, 2001). 44% ofsmokers said that the new warnings increased their motivation to stop smoking and 27% saidthat the warnings had motivated them to smoke less inside their homes. 38% of those who hadattempted to stop smoking said that the warnings were a factor in motivating their attempt.62% of smokers thought that the new warnings made the cigarette pack look less attractive, and17% said that they had put the pack away on at least one occasion because they did not wantothers to see the health warning.The European Union (EU) and Brazil have since followed Canada’s leadership by adopting

similar measures, and Thailand and Singapore look set to follow. The new EU pack health

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warnings are due to appear by October 2003; however, transnational tobacco companies havetaken action in the European Court of Justice to try to defeat the directive that mandates allEU member states to implement the new warnings. A similar legal challenge defeated the EUdirective on advertising, which would have required all EU states without a ban on tobaccoadvertising (including the UK) to legislate for one.

5. Other tobacco control policy

In addition to health warnings, an ideal policy of tobacco control includes a ban on all forms ofpromotion, regular price increases through taxation, on-going programmes of public educationand public information, the establishment of non-smoking as the norm in public places andassistance to help people to stop smoking.

6. Health education

For many years, public education of young people, mostly through programmes administeredthrough schools, tended to follow traditional medical and adult models, informing childrenabout risks which, even to the most imaginative, must have seemed so remote in both timeand experience as to be of little relevance. Indeed, most experts in the field now believe that thelarge majority of health education aimed at children has been ineffective or, worse, counter-productive (Borland, 1997), by unintentionally portraying smoking as a ‘forbidden fruit’ torebellious adolescents. It is not surprising, therefore, that this is one of the few aspects oftobacco control policy that the tobacco industry itself says that it supports and is currentlypromoting as part of a public relations campaign to try to improve its image.The continued uptake of smoking by young people—the large majority of smokers in the UK

begin the habit in their teens—and a disappointing rate of attempts to stop smoking amongadult smokers suggest that the perception of risk is still far from adequate. Addiction servesto limit the success of those who do decide to give up, who tend to cite the desire to avoid therisks as the most important reason for their efforts. Health educators have attempted to deviseprogrammes with a positive lasting effect on behaviour among both children and adults, but alack of funding, inconsistent Government policy and the activities of a powerful vested interestagainst success have all played their part in reducing an accurate perception of risk and riskreduction by potential and current smokers. The continuous barrage of attractive images andother references in the media linking tobacco with positive desirable concepts operates againstlow profile health warnings and intermittent health education about tobacco.

7. Tobacco promotion

One of the aspects of tobacco control policy that is most strongly resisted by the tobacco indus-try (and therefore probably among themost effective single components of a long-term strategy)is a ban on all forms of tobacco promotion. An example of how the tobacco companies andtheir advertising agencies perceive the power of advertising to affect people’s perceptions of riskmay be seen from documents relating to British American Tobacco’s Canadian subsidiary,Imperial Tobacco, in relation to a ‘light’ brand aimed at Canadian women.

‘Our woman is front and centre. She is unquestionably the star. She is happy and healthy. She is not aphysical fitness fanatic, but loves to take part in healthy, fun activities. Andwhile she is good at them, sheis not a champion. . . . As the strategy dictates, her activities are not too strenuous or aerobic. Smokinga low [tar and nicotine] cigarette would be a logical extension of the lifestyle depicted. . . . The theme


“Feeling extra good, Smoking Extra Mild”, is a reflection of the feeling that seems to be indicated byprior research, that is: “Even though I smoke, I like to be active and look after myself—so I smoke anextra mild cigarette”’ (Imperial Tobacco Ltd, 1996).

In other words, the strategy of the advertising campaign was to acknowledge women’s fearsof the risks that they faced by smoking, and to present this brand as less dangerous than oth-ers, which it almost certainly was not, to the extent that smoking it was compatible with beinghealthy. By implication, women could be reassured that the brand was sufficiently low risk thatthose who smoked it did not need to give up smoking.Tobacco promotion works against people’s full understanding and unequivocal acceptance

of the risks of smoking. Over many years, public attitude surveys have found that smokers’justification for their continued smoking frequently includes the suggestion that, if smokingwere as bad as health experts say, the Government would not allow the promotion of cigarettes(or even their sale, according to some).

8. Social acceptability of smoking

It has been clear for many years that tobacco companies, which monitor factors that are knownto affect their sales, rate the public acceptability of the smoking habit as the most crucial factoraffecting sales in the long term. In 1979, a tobacco industry delegation attended theWorld Con-ference on Smoking and Health and a subsequent memorandum summarizing the delegation’sfindings included the statement that ‘the social acceptability issuewill be the central battlegroundon which our case in the long term will be lost or won’ (Tobacco Documents, 1998). Just as withthe threat of a ban on advertising and other forms of promotion, the restriction of smoking inthe workplace and in other areas where people spend a significant proportion of their wakinghours not only makes smokers smoke less but also diminishes the social acceptability of thehabit.

9. Policy successes in the UK

Turning to areas of success in public health policy on tobacco, the close relationship betweenthe price of cigarettes and consumption has been exploited to particularly good effect in theUK, strongly contributing to a decline in consumption in the past quarter-century (Townsend,1998), though in recent years the effect has been increasingly undermined by smuggling. Evi-dence of complicity by the manufacturers is so great that a Department of Trade investigationhas been set up.Two other factors have played a special role in the UK’s reduction in smoking. First, the

choice of doctors as the subjects in Doll and Hill’s pioneering prospective study begun in 1951,perhaps the most substantial cornerstone of the epidemiological evidence of smoking as a causeof lung cancer and other serious diseases, led to doctors being among the first groups to reducetheir smoking significantly and, in turn, to become active in trying to reduce smoking-induceddisease, both in their clinical work and also through medical organizations. Institutional activ-ities included the world’s first independent review of the burgeoning scientific evidence by theRoyal College of Physicians of London in 1962, which led to considerable media coverage andalso, in the USA, to the first report on the topic by the Surgeon General, in 1964.Second, and related, has been 30 years of continuous activity to ensure that journalists are

well informed on tobacco control issues and cover them accordingly, far more than in othercountries which have lacked a comparable ‘media advocacy’ operation. This has been among

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the central work of Action on Smoking and Health, which was set up by the Royal College ofPhysicians after its second report on smoking, in 1971.

10. Prospects for the future

While this article was being drafted, it was reported that the Government had decided to backa private member’s bill in Parliament, to implement its own stated intention of banning mostforms of tobacco promotion in the UK. In addition, pressure is continuing to mount in Parlia-ment, among medical and health organizations and the general public, for the Government totake action to restrict smoking in public places and in theworkplace for, although there has beennotable progress in the last quarter-century in public transport, Government offices and otherareas, smoking remains the norm in many public places. Thus the next year or twomay herald anew era in which the problem at last begins to receive the legislative and administrative prioritythat it so clearly deserves, which could include greater efforts to enable people to appreciate theunique risks of smoking, and less deliberate efforts to prevent them from doing so.

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