Harvard Public Health Review Winter 2007
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Leaders worth folowing: HSPH celebrates distinguished faculty and alumni no smoking sign in France
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Who could imagine Paris without its smoke-filled cafes? As it turns out, the French government can. For those who would dare smoke in Parisian establishments, the government has a startling new message: “Veuillez fumer dehors!” French smokers aren’t the only ones stepping outside, however. Smoke-free policies are sweeping the globe.

In 2004, Ireland became the first country to establish a national ban on smoking in all indoor workplaces, including restaurants and bars. Since then, more than a dozen countries have followed suit. For example, France enacted a ban in February 2007 covering offices, schools, and hospitals that will extend to all public establishments in January 2008. The European Union is considering comprehensive smoke-free legislation for all 27 member nations. Meanwhile, more than one-third of U.S. states have enacted smoke-free policies, most of them since 2005.

Exporting expertise
Fueling the trend is a small but influential group at the Harvard School of Public Health (HSPH) led by Greg Connolly, professor of the Practice of Public Health in the Division of Public Health Practice, and the division’s director, Howard Koh, the Harvey V. Fineberg Professor of Public Health Practice. The two researchers, who have been among those leading the charge for worldwide tobacco control at both grassroots and government levels for more than two decades, describe Ireland’s 2004 ban as a critical “tipping point” in the New England Journal of Medicine in April, joined by co-author Luk Joossens of the Association of European Cancer Leagues. A list of countries that have since adopted smoking bans underscores tobacco warriors’ progress to date.

Connolly, an international ambassador for sweeping policies that safeguard the public against passive smoking, shuttles from one country to the next, conducting local research, coordinating anti-smoking media campaigns, and advising government officials. In many U.S. states and in countries that include Ireland, El Salvador, Greece, China, Taiwan, Philippines, Poland, Armenia, Israel, Thailand, and, most recently, the Mediterranean island nation of Cyprus, Connolly goads policy makers to adopt proven tobacco-control strategies.

“You have to build the capacity to do research locally, then add a heavy dose of aggressive anti-tobacco advertising to foster social change and build enough political will to raise taxes, ban smoking in public places, and offer people treatment for tobacco addiction,” he says, outlining key tactics in a nutshell (see also sidebar on at right). Covering a wall in his office is a world map studded with pushpins, each marking a site where research by HSPH faculty, alumni, and their collaborators is under way.

Connolly honed his approach while heading the Massachusetts Tobacco Control Program, the job he held before coming to Harvard in 2004. Under the leadership of Koh, at the time the state’s public health commissioner, and Connolly, Massachusetts cut cigarette consumption nearly in half. If anyone needed proof that comprehensive tobacco-control initiatives could reduce consumption, this was it. Now, Connolly, Koh, and their HSPH colleagues are increasingly focusing attention on developing countries, where smoking rates remain high and where multinational tobacco companies see enormous markets ripe for exploitation.

Targeting Asia
Figuring prominently on these companies’ radar screens is the Asia Pacific region, the fastest growing tobacco market in the world. In 2000, Connolly was made a Commander of the Fourth Order by the King of Thailand for his efforts with the U.S. Congress, the World Health Organization, and the WHO-backed General Agreements on Tariffs and Trade (GATT) to halt U.S. trade sanctions imposed against Thailand for its refusal to import and advertise cigarettes. Both Connolly and Koh are active in the Asia Pacific Association for the Control of Tobacco, a regional nongovernmental organization based in Taiwan that aims to fight Big Tobacco while promoting smoke-free policies for its ten member nations. China, for example, with 350 million smokers, most of them men, has the highest per-capita density of tobacco users on earth. And no wonder: there, the tobacco industry is controlled by the central government and represents the second-largest source of tax revenues.

Philip Morris has begun a joint venture with the China National Tobacco company to produce Marlboros in the country, Connolly says. As the world’s largest producer of tobacco products, China National Tobacco supplies 1.7 trillion cigarettes to Chinese consumers annually. Warns Connolly: “Both companies stand to benefit from the partnership—at the expense of global public health.” Philip Morris will produce cheaper Marlboros by lowering its labor and manufacturing costs, he says, while China National Tobacco will be able to sell its own cheap brands through Philip Morris’s international distribution system.

By acquiring or linking up with national monopolies in developing countries, transnational tobacco companies are expanding their markets dramatically. “And that,” Connolly says, “is disastrous for the world.”

Women and children next
Targeted by industry advertising, women and youth in the developing world are particularly vulnerable. Seven times fewer women than men smoke in developing countries, but their numbers are growing. The same can be said for the developing world’s schoolchildren, among whom smoking rates now average 20 percent, according to the WHO. HSPH researchers in developing countries—where tobacco companies are often poorly regulated—routinely find cigarette billboards clustered near playgrounds and schools at densities far higher than those near adult-centered locations. Throughout the United States, Canada, Australia, New Zealand, and other wealthier nations, however, such billboards are banned.

Koh stresses that smoke-free policies in developing countries face unique challenges, in part owing to the tobacco industry’s widespread influence. “The industry weaves its message into all segments of society, so initially people may feel powerless to voice their outrage,” he explains. “But fortunately, tobacco control is rapidly becoming a strong and vibrant concept internationally. The 21st century is witnessing a paradigm shift, once considered impossible, whereby entire countries are declaring themselves smoke-free in indoor public places. Mounting progress across the globe is making smoking history worldwide.”

Connolly sums up the key to successful tobacco control with one word: “KILLS—Keep it Loud and Local, Stupid,” he says with a chuckle. “You have to generate local debates, create local science, and empower communities.” Doing that requires a lot of legwork. In resource-poor countries, Connolly and his collaborators use sophisticated yet low-cost, effective technologies to gather baseline data on tobacco risk. Using portable air sampling devices, for example, they measure air quality, including childhood second-hand smoke exposures, indoors and in real time. With digital cameras with GPS tracking linked to Google Search, they can map cigarette advertising near youth-oriented schools, playgrounds, and other locations. They also scour health and economic data to quantify smoking’s death toll and financial impact. Many HSPH students set off to collect this data during the School’s 2007 Winter Session.

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5 Steps to a Successful Tobacco Control Plan

through taxation to reduce tobacco consumption

to protect nonsmokers and make smoking in public socially unacceptable

to educate the public and change social norms

to help people quit

to make sure the plan is working, and to document smoking trends

Related Links

The Leading Preventable Cause of Death and Disease
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"Where There's Smoke"

Division of Public Health Practice

Harvard School of Public Health | Cyprus International Initiative

Greg Connolly

Howard Koh



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