In Venezuela, a splashy publicity campaign earlier this year featured weeks of mystery-laden television and print ads heralding the imminent arrival of a blue planet, at which time the promotional stunt culminated with a massive fireworks display. Despite public expectations of an otherworldly encounter, the event turned out to be the unveiling of a new brand of Kent cigarettes. The cleverly timed buildup prompted such a feeling of insult among the citizenry that Fundapatria, a prestigious foundation devoted to promoting national values, filed a suit seeking criminal penalties against the tobacco company, saying it had alarmed the community, associated cigarettes with mind-expansion qualities, and contributed to the cultural deterioration of the country and its youth.

In Barbados, the national Heart Foundation objected to British American Tobacco's 1997 sponsorship of the island's internationally known Crop-Over Festival. Foundation President Dru Symmonds noted: "This development is counter to the significant efforts which have been made in creating an awareness of healthy lifestyles throughout our nation in recent years."

These are just two of the many skirmishes in the rapidly escalating international tobacco wars. They involve drugs and money, although in this case the drugs and money are perfectly legal. And while substance abuse experts consider nicotine to be more addictive than heroin or cocaine, tobacco products are still sold openly everywhere in the world.

Public outcry in the United States against the tobacco companies has reached a fever pitch, and in mid-1997, the industry agreed to a US$ 368 billion settlement that effectively ends a century or more of seductive tobacco advertising and popular naïveté about nicotine's deadly effects.

Tobacco Wars Spread South

The first battles pitting public health advocates against big tobacco companies began in the U.S. and Canada, but now they are spreading throughout Latin America and the Caribbean as scores of private physicians and community organizations band together in tobacco prevention and control activities. Only 4% of the world's smokers are in the U.S., and of the 3 million tobacco-related deaths each year, 85% occur in other countries.

As the tobacco giants watch the numbers of smokers dwindle in North America, promotional efforts are turning to the developing nations, where there are fewer restrictions and millions of potential customers. "And in many countries," according to an international group of physicians that includes the president of the International Union Against Cancer, "they are using slick and deceptive advertising and marketing techniques that target children, especially girls, in ways that would never be tolerated in the United States."

The U.S. exports about US$ 1.3 billion in raw tobacco and US$ 4.9 in cigarettes each year, according to U.S. Department of Commerce figures. The Philip Morris Company is the 10th-largest U.S. corporation in terms of revenues, earning more than Chrysler, Texaco, Pepsi, and Procter & Gamble. Philip Morris and the other tobacco companies are now facing a spate of lawsuits that began when one tenacious opponent, a Florida lawyer named Norwood Wilner, won a product liability suit against Brown & Williamson Tobacco Corporation that resulted in a US$ 750,000 award. Wilner showed that the company's executives, following research in 1963 that linked cigarette smoking to lung cancer, did not disclose the results to the U.S. Surgeon General, who at that time was preparing the first major public announcement that tobacco use posed a serious health hazard. The corporation instead kept the results secret and embarked on a 30-year strategy of admitting nothing, a tactic that the rest of the tobacco industry quickly adopted as well.

The August 1997 court verdict proved disastrous for tobacco stocks: Philip Morris alone lost US$ 12 billion of market value just after the settlement was announced. Wilner says he will continue suing the industry, and that juries are now ready to make tobacco companies pay. His success, Fortune magazine says, reflects--as much as it has altered--the evolving dynamics of the tobacco wars.

Tobacco Giants Make a Deal

Now tobacco companies are changing their stance. On 20 June 1997, the attorneys general from nearly 40 U.S. states announced a tentative settlement of tobacco litigation that they say will have a major impact upon the country's public health. Under the agreement, the states would accept US$ 368 billion--some US$ 57 billion more than the average annual U.S. public health budget--from the tobacco industry in exchange for rigid controls on advertising and sales to minors and immunity from future class-action lawsuits.

But the settlement, which needs the approval of Congress and the President's signature to be final, is controversial among public health groups. At a recent congress on preventive cardiology, more than 2,700 doctors from 75 countries agreed that control of tobacco is essential to reduce the burden from heart disease, but cautioned: "We urge the veto of any settlement proposal which does not explicitly require effective actions to reverse the tobacco epidemic everywhere in the world."

As the tobacco wars rapidly spread southward, other countries are looking at ways to get money from tobacco companies. Costa Rica's state social security system has hired a Texas law firm to file suits against two tobacco companies to recover some US$ 534 million the country has spent treating people with smoking-related diseases.

These types of actions are likely to continue since the tobacco industry is huge, and its power is international. The three largest tobacco firms, all ranked among the top 160 companies in the world, are Philip Morris, which made US$ 5.4 billion in profit last year; British American Tobacco, which made US$ 2.3 billion and Japan Tobacco, whose profits were US$ 737 million.

The World Health Organization (WHO) estimates that 10 million people will die annually from tobacco-related diseases by the 2020s and 70% of these deaths will be in developing countries. In Latin America and the Caribbean, an estimated 135,000 people die each year from tobacco-related diseases.

Smokers Start Young

The public health focus on smoking and children is important because each day, 3,000 young people become regular smokers in the U.S., and one-third of them will eventually die from tobacco-related diseases. The average youth smoker begins at age 13 and becomes a daily smoker before the age of 15. Clearly, the way to a smoke-free society is to discourage future generations from lighting up.

Dr. David Kessler, former Commissioner of the U.S. Food and Drug Administration, in an address at the Pan American Health Organization's World No-Tobacco Day in May 1997, said: "Ninety percent of all smokers start in their teenage years. Nicotine addiction begins as a pediatric disease fueled by powerful images and marketing techniques." He noted that before R.J. Reynolds Tobacco Company launched its high-profile Joe Camel campaign targeted toward adolescents, Camel cigarettes--"which used to be a brand associated with men in their 50s and 60s"--claimed only 3% of the market. Now that share is 13-16%, smoking rates among children are at a 17-year high, and more cigarettes are manufactured than at any other point in U.S. history. Kessler concluded that "it is time for the industry to take responsibility for this epidemic of youth addiction that has enormous public health consequences for the future."

A recent Canadian study showed that teenagers are three times more responsive than adults to cigarette advertising. Richard Pollay of the University of British Columbia looked at nine cigarette brands and found that whenever a brand's advertising increased, teen smoking of that brand was three times more likely to increase than adult smoking. And three brands with eye-catching ads--depicted by the Marlboro Man, Joe Camel, and Newport cigarette's "fun couples"--captured twice as much of the teen smoking market as the adult market, he reported.

Money to Burn

Philip Morris's U.S. advertising budget is US$ 257 million a year, while R.J. Reynolds has some US$ 75 million to spend on promotion. By way of comparison, the annual total income available for Pan American Health Organization programs to improve health and living conditions in the 35 countries of the Americas, with a population of some 800 million, is about US$ 248 million.

The focus of new ad campaigns is overwhelmingly youth, who erroneously believe that the large majority of adults and their peers use tobacco, and research shows that overestimating smoking prevalence is one of the strongest predictors of smoking initiation. According to a new U.S. Institute of Medicine (IOM) report, "tobacco use is a learned and socially mediated behavior. Experimenting with tobacco is attractive to children and youths because of associations they learn to make between tobacco use and the kind of social identity they wish to establish."

The youthful impression that "everyone does it" is reinforced by neighborhood billboards promoting tobacco products, restaurants and shopping malls where tobacco use is permitted, and cultural and sporting events that either are sponsored by the tobacco industry or where tobacco logos are prominently displayed. All of these factors, concluded the IOM report, contribute to the perception that tobacco consumption is a social norm among "attractive, vital, successful people who seek to express their individuality, who enjoy life, and who are socially secure."

Nicotine Casts a Wide Net

Tobacco control experts say that once young people are hooked on nicotine, they will most likely continue smoking through adulthood, and lifelong smokers, according to WHO, have a 50% chance of dying from tobacco. Also, studies in the United Kingdom have shown that smokers in their 30s and 40s are five times more likely to have a heart attack than nonsmokers.

The growing international tobacco epidemic is obviously a public health problem, yet it is much more. A World Bank economist has estimated that tobacco use results in a global net loss of US$ 200 billion per year, with half of these losses occurring in developing countries. These costs include direct medical care of tobacco-related illnesses, absenteeism from work, fire losses, reduced productivity, and foregone income due to early mortality. There are other substantial, yet unquantifiable costs, as well: the reduced quality of life for smokers, and the suffering brought upon those whose lives are affected by the loss or illness of a loved one due to tobacco. There are, in fact, few sectors of society untouched by tobacco's influence.

Winning the War

There is now a widespread consensus that tobacco prevention and control activities must center on promoting a tobacco-free social norm and discouraging future generations from starting to smoke. As the North American climate becomes increasingly hostile, tobacco manufacturers are turning to the developing world, where the absence of strong legislation and regulatory controls will allow them to replace lost revenues with relative ease. "In most countries, the worst is yet to come," says Richard Peto of Great Britain's Imperial Cancer Research Fund.

Yet the tide can be turned. The numbers of individuals, community groups, and governments around the world committed to achieving success in the war against tobacco are growing daily, proving that it is possible to change the course of public health history.

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Daniel Epstein is a Washington, D.C.-based journalist in charge of media relations for PAHO's Office of Public Information.