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Tobacco and the developing world
Published in ProCOR

Bernard Lown, MD


The opium wars of the 21st century: Tobacco and the developing world

The opium wars of the 21st centry: Tobacco and the developing worldSince the 1964 report of the Surgeon General's Advisory Committee on Smoking and Health 38 million adults in the United States have quit smoking. (1) During the  1990's, the retreat of cigarette  companies has become a near rout in some  industrialized countries.  The tobacco industry, quite to the contrary,  is not on its knees nor about to surrender.  Its long range global strategy is to maintain  sales roughly constant in industrialized countries,  while investing mammoth resources to increase market share in the Third World, in the former Soviet Union and in Eastern Europe.  The struggle against tobacco is not being won, it is being relocated.   In the past decade United States tobacco consumption dropped 17 percent while exports have  skyrocketed 259 percent.  At present, the two American giants, Philip Morris and R.J. Reynolds sell more than two thirds of  their cigarettes overseas and half their profits come from foreign sales. (2)

The tobacco wars of the next century will increasingly be waged among vulnerable populations ill equipped to cope with the slick  marketing techniques and the dirty tricks perfected by the tobacco industry.   Most developing countries have no  advertising controls, lack adequate health warning requirements, and have a dearth of   pressure groups campaigning for stricter tobacco controls.  They  have set no age limits, nor imposed restrictions  on smoking  in public places.  Their populations are poorly educated on the health hazards nor is information being provided to the burgeoning numbers of teen-agers who are most  susceptible to advertising hype.

Tobacco already exacts an inordinate  toll in the developing world.  In Mexico, according to the Center for Disease Control (CDC), death rate for all smoking related disease has  increased substantially, ranging in mortality increases of  60% for cerebrovascular disease to   220%  for lung cancer. (3) In Brazil cigarette-related disease now leads infectious diseases as the principal cause of death.(4)    In Bangladesh, as a result of increased   smoking, cancer of the lung has become the third most common cancer among men and perinatal mortality is 270 per 1000 /children of smoking mothers-more than twice the rate for children of nonsmokers. (4)  In India, a six-fold increase in mortality from bronchitis and emphysema has been  noted, coincident with that country's skyrocketing cigarette consumption.(4,5 ) In developing countries, not only is the use of tobacco surging, but the cigarettes are more addictive and more lethal  because of  higher tar and nicotine content.

In Asia smoking is growing at the fastest rate in the world accounting for half of global cigarette use . The largest number of  recruits are  among the young and women. (6)  The tobacco industry finds the Asian market particularly inviting because of its size and the love for smoking.  In China 61 percent of men and 10% of women over 15 now smoke. These  320 million smokers consume   1.7 trillion cigarettes annually.  While the Chinese account for a third of all smokers world wide, as yet this lucrative market has not reached its potential limit. The staggering health costs is a reckoning for the future.  The  Chinese Academy of Preventive Medicine forecasts  3.2 million deaths annually  by the year 2030. (7, 8)

The United States has played a key role in promoting the global consumption of tobacco.  More than a century ago the American tobacco magnate James B. Duke entered  China. (9) Until his arrival very  few Chinese smoked, mostly older men using a bitter native tobacco, usually in pipes.  Duke hired "teachers", who traveled from village to village in Shantung province, marketing  a milder North Carolina tobacco leaf and  instructing  curious onlookers how to light up and hold cigarettes. Duke installed the first mechanical cigarette-rolling machine in China and unleashed a panoply of promotional materials, including cigarette packs displaying nude American actresses.  He set the precedent of having the United States government pressure  the Chinese  to  permit the import of American cigarettes.

Pushing  deadly merchandise  abroad if  anything it has intensified in recent years. In 1985 when US began its campaign to open Asian markets to tobacco  exports, it shipped 18 billion cigarettes; by 1992 the figure had risen to 87 billion or nearly five-fold.  The US government, while discouraging smoking at home, successfully pressured Japan, Taiwan, South Korea and Thailand into breaking their domestic tobacco monopolies to allow the sale of American cigarettes.(6)  These national monopolies  did not advertise and  sold cigarettes largely to male adults.  After US companies penetrated their markets smoking soared among young people. Two years after the entry of American cigarettes in  Japan, their import increased by 75 percent with 10-fold increase in the number of television advertisements to encourage smoking.  The US  broke a healthy taboo against smoking by Japanese women.  In but a few years the number of women smokers more than doubled. (6, 10)

In a single year after the ban against American tobacco was lifted, smoking among Korean teenagers rose from 18.4 to 29.8 percent and more than quintupled  among female teens, from 1.6 to 8.7 per cent. (2) A poll among two thousand high school students in Taipei, Taiwan indicated that 26% boys and 1%  of  girls smoked a cigarette. After American tobacco companies entered their market  in a survey of eleven hundred high school students, the figures shot up to  48 percent of boys and 20 percent of girls. (6) Words like Marlboro, Winston, Salem, and Kent have entered the vocabulary of every Asian nation.

The American government engaged in activities that would have provoked outrage if carried out in its own country.  The US Trade representative refused the Taiwanese proposal not to allow advertisement in magazines read primarily by teen-agers. (6) The Taiwanese were not permitted to move the health warnings from the side to the front of the package nor increase the type size, nor  were they allowed  to prohibit wending machine sales.  An unconscionable American trade imperialism  fuels  the rise in smoking. This prompted the former U.S.  Surgeon General,  Dr. C. Everett Koop to say about his country,  "People will look back on this era of the health of the world, as imperialistic as anything since the British Empire-but worse." (10).

Even without the exercise of government muscle on their behalf, the tobacco titans present a formidable challenge to an unwary public. Tobacco promotion is pursued aggressively in less developed countries, with advertising budgets for many countries surpassing  national funds appropriated for health research. The tobacco  companies invest prodigious resources in targeting women and children.  According to  a recent editorial in the New York  Times,   "Hong Kong is one of the battlefronts of the modern-day Opium War. While Britain went to war last century to keep its Indian-grown opium streaming into  Chinese ports, today American tobacco companies win profits and build addiction throughout Asia." (11)

In Hong Kong, where American tobacco blends make up 94 percent of the market, hip clothing stores pass out cigarettes free to their customers. Advertising is geared to the young in Asia  by sponsoring  sporting events and pop concerts with free disco passes given out in return for empty cigarette packs. The Marlboro bicycle tour is the biggest national summer sport in the Philippines. (5) Salem cigarettes sponsor a "virtual reality" dome, where teenagers attack each other with laser guns. (12) Empty packs of American cigarettes can be redeemed for tickets to movies, discos and concerts.  In Kenya, cigarettes with brand names such as Life and Sportsman are promoted as the passport to success, health, and a Western lifestyle( 13). In Taiwan, most smokers prefer Long Life, Prosperity Island, or New Paradise.(14)

The financial stakes  are enormous.   The international trade in tobacco is dominated by six multinational conglomerates, three of which are based in the United States (Philip Morris, RJ. Reynolds, and American Brands). Together, these six companies account for 40 percent of the world cigarette production and almost 85 percent of the tobacco leaf sold on the world market.(15)  Since 1970, as American  domestic smoking rates began to decline, intensive marketing campaigns supported by vast governmental resources tripled America's export of tobacco. Sales of Philip Morris in Africa is growing at 20% per year. It is projected that international sales of Philip Morris will jump 16% in 1997 to 764 billion cigarettes with a projection of 1 trillion by the year 2000. Foreign smoking is the major reason for the profitability of Philip Morris with earnings of $6.3 billions in 1996.  This company now ranks third in profitability in the US behind Exxon and General Electric. By virtue of their great wealth the tobacco conglomerates are a world power having more political clout than a majority of developing nations.

From  a public health  perspective what is happening in the developing world is an unprecedented calamity.  We know but little of the full impact of smoking on malnourished disease-ridden people.  There is evidence that tobacco may interact synergistically  with infectious diseases and with environmental hazards to cause increases in certain cancers. For example, tuberculosis which is widespread in developing countries, may enhance the risk of lung cancer and is further amplified by smoking. (16))  In Egypt, Schistosoma haematobium has been associated with an increased prevalence of bladder carcinoma among smokers (17) In less-developed countries, poorly controlled occupational hazards, such as organic dusts, uranium, or asbestos, may act as synergistic co-carcinogens in workers. (5) In addition,  the health costs of fires resulting from cigarette smoking in countries where dwellings are often constructed of highly flammable materials is part of the tragic impact of tobacco.

The burden of disease due to tobacco is incalculable. Richard Peto and colleagues, (18)  suggest that by the year 2025 mortality ascribable to global tobacco use will exceed 10 million annually and about 70% of the deaths will be in the developing countries.  Such  colossal mayhem is unprecedented in the annals of human barbarism.  Cigarettes can not be permitted as a trade weapon that wastes the lives of unwitting victims to enrich the coffers of corporate America. The world has outlawed chemical weapons but tobacco is far more deadly.  United States health professionals have an awesome moral burden to speak out and unrelentingly combat this global scourge.




1. The Surgeon General's 1990 report on the health benefits of smoking cessaction: executive summary MMWR 1990;39(RR-12):1-10.
2. Weissman R. Tobacco's global reach. The Nation. 1997; July 7, p 5.
3. Death rate from leading causes of smoking related deaths have tripled since 1970 in Mexico JAMA July 19,  1995 vol 274  p 208) During 1970-1990.
4. Nath UR. Smoking in the Third World. World Health. June 1986:6-7.
5. Yach D. The impact of smoking in developing countries with special reference to Africa. Int J Health Serv 1986; 16:279-92.)
6. Sesser S. Opium war redux. New Yorker Magazine. 1993;September 13, p 78-89.
7. Faison S. China next in the war to depose cigarettes. New York Times August 27, 1997.
8. Tomlinson B.  China bans smoking on trains and buses. BMJ. 1997;314:772.
9. Grayson R.  Big tobacco has eyed china for a century. New York Times. Letters to Editor. September 14, 1997
10.Jackson D.Z.  US shouldn't help big tobacco sell its deadly wares abroad .     Boston Globe  1997,  May 16
11.Editorial. New York Times . "Selling Cigarettes in Asia"  1997; Sept 10.
12.Barry M.  The influence of the U.S. tobacco industry on the health, economy, and environment of developing countries .  Sounding Board NEJM 1991; 324:917-919.
13.Yach D. The impact of smoking in developing countries with special reference to Africa. Int J Health Serv 1986; 16:279-92.
14.Jones D. Spotlight on Taiwan: foreign brands grab a big share. Tobacco Reporter. January 1989:324.
15.Connolly G. The internationd marketing of tobacco. In: Tobacco Use in America Conference, Houston, Texas, January 27-28, 1989. Chicago: American Medical Association, 1989:49-66.
16.Willcox PA,  Benatar SR, Potgieter PD. Use of the flexible fibreoptic bronchoscope in diagnosis of  sputum-negative pulmonary tuberculosis. Thorax  1982; 37:598-601.
17.Makhyoun NA. Smoking and bladder cancer in Egypt. Br J Cancer 1974; 30:577-8
18.PetoR, Lopez AD, Boreham J, Thun M, Heath C Jr Mortality from tobacco in developed countries: indirect estimation from national vital statisitics. Lancet 1992; 239:1268-78