Changing the Trajectory of the Global Tobacco Epidemic

May 24, 2024, by Mark Parascandola, Ph.D., M.P.H.

This year marks 60 years since the release of the first report of the U.S. Surgeon General on Smoking and Health, one of the most influential documents in public health history. On Saturday morning, January 11, 1964, Surgeon General Leroy Burney led a closed-door press conference in the State Department auditorium in front of 200 reporters, describing the report’s conclusions that smoking was a cause of lung cancer and presented a major health hazard. The report’s findings, the product of two years of work by a committee of experts, were expected to generate sizeable media attention and public response. The press conference was held on a Saturday to dampen potential impact on financial markets.

The completion of the report was a massive undertaking. The committee worked in secrecy in the basement of the National Library of Medicine on the NIH campus, reviewing volumes of literature and assembling their conclusions. Precautions were taken to ensure that the committee’s notes and deliberations remained confidential and to insulate the committee members from political or tobacco industry influence. In their newly published book, Clearing the Air: The Untold Story of the 1964 Report on Smoking and Health, former NCI staff scientist Donald Shopland and co-authors provide a behind-the-scenes view into the “organized chaos” of the committee’s workings as they navigated scientific disagreements, political pressures, and tobacco industry interference (1). 

Now, 60 years later, the World No Tobacco Day 2024 theme is ‘Protecting Children from Tobacco Industry Interference’. While public health leaders were expressing concern in the early 1960s over tobacco industry advertising and smoking teenagers, the Surgeon General’s report had little to say about protecting children or tobacco industry interference. A brief section addressing smoking initiation in children emphasized family and peer influences with no mention of the tobacco industry. However, since that time, numerous studies have documented how cigarette manufacturers actively designed and marketed their products to teenagers (2). For example, milder brands and flavored products were promoted to young people to get them to start smoking. Companies also employed advertising themes that appealed to youth and sponsored music festivals and concerts. 

In recent years, with expanded tobacco control policies and counter-marketing campaigns, cigarette smoking among youth has fallen significantly. According to data from the National Youth Tobacco Survey, current cigarette smoking (within the past 30 days) among high school students dropped from 15.8% in 2011 to 1.9% in 2023 (3). But the introduction of a range of novel nicotine and tobacco products, including flavored e-cigarettes and nicotine pouches, has complicated the picture. E-cigarettes are now the most commonly used tobacco products among youth in the U.S. Data from the Global Youth Tobacco Survey similarly shows that while cigarette smoking among adolescents aged 13-15 years has decreased in the majority of countries, the use of other tobacco products has either increased or remained the same (4). Today, many years after the 1964 report, tobacco industry marketing continues to contribute to tobacco use among youth around the world. 

In Africa, the number of people using tobacco, particularly adolescents and young adults, is projected to increase in the coming years, driven by a rapidly growing population and an expanding market for tobacco products. With a median age of 18.8 years, Africa has the youngest population of any world region. As multinational tobacco companies scale up their investments in Africa, they have sought to make use of familiar promotional tactics, including sponsorship of concerts and events for young people, promotion of single cigarette sales, price promotions, and social media influencers (5). Researchers monitoring the industry have also documented  how tobacco companies have pressured African political leaders to stall tobacco control efforts (6). 

However, a future epidemic of widespread youth tobacco use in Africa is not a foregone conclusion. Smoking prevalence in Africa remains low compared with other world regions, providing a window of opportunity to intervene. Today, unlike in 1964, a range of evidence-based policies and interventions exist to reduce tobacco use. The WHO Framework Convention on Tobacco Control provides a legal framework to support the implementation of tobacco control measures. And, in Africa, a growing network  of researchers, many of whom are supported by the NCI, along with advocates are working to advance tobacco control and counter efforts of the tobacco industry (7). Furthermore, discussions around “endgame" strategies have brought forth innovative proposals to dramatically reduce or phase out sales of tobacco products, such as SmokeFree Generation policies that prohibit sale of tobacco to anyone born after a particular date (8). A recent analysis of endgame readiness found that many low- and middle-income countries, notably those with low tobacco use prevalence and a robust tobacco control policy environment, are already well-positioned to implement endgame-type policies (9). 

While tobacco control efforts around the world have had an enormous impact on global health, tobacco industry marketing and interference continue to promote tobacco use, particularly among youth. However, the tools exist to set a different trajectory for the next 60 years. Scientific research has been critical to past success in reducing tobacco use, and NCI continues to support research that will help us to shift course.