Journal of Public Health Medicine
Vol. 23, No. 2, pp. 91–97 Printed in Great Britain
For debate Lessons from tobacco control for advocates of healthy transport Jennifer Mindell
Summary Many parallels can be drawn between cigarettes and motor vehicles, smoking and car driving, and the tobacco and the auto/oil industries. Those promoting healthy and sustainable transport policies can learn lessons from tobacco control activities over the past 50 years. Evidence-based legislation is more effective than negotiated voluntary agreements between industry and government. Media advocacy is crucial to reframe the issues to allow changes in national policies that facilitate healthier choices. Worthwhile public health policies seen as a threat by multinational companies will be opposed by them but active national and international networks of healthcare professionals, voluntary organizations, charities and their supporters can match the political power of these industries. Keywords: health protection, policy, smoking, transport
The product Many parallels can be drawn between cigarettes and private motor vehicles. Both have a wide range of serious adverse health effects on those who use them and those around them (Table 1). Less severe effects are also widespread: the nuisance of eye irritation or road traffic noise, the smell of cigarette smoke or motor vehicle exhaust, and precipitation of symptoms in people with asthma.
The consumer (Tables 2–4) Smoking prevalence goes through three phases. Currently, countries of Central and Eastern Europe (CEE) and the developing world are experiencing an exponential rise (phase ‘a’). The number of smokers in many countries in Europe, for example Greece, Germany, Italy and Denmark, has reached a plateau (phase ‘b’), whereas prevalence in the United Kingdom, United States, Canada and Australia is declining (phase ‘c’). Both early adopters and early quitters come from the more educated and wealthier members of the population. The social class pattern alters markedly, with more affluent smokers in phase ‘a’, no
social class gradient in phase ‘b’, and a marked inverse gradient in phase ‘c’, with smokers found mostly among the more disadvantaged in society. Women usually start smoking later than men within any country, with a lower peak prevalence as health education and other tobacco control measures are implemented as evidence of harm accumulates. Car ownership in the United Kingdom is still in phase ‘a’, with continuing but decreasing inequalities in car ownership by age, sex and income (Figure 1a). We do not know whether the rise will continue, with more cars per household, or whether it will stabilize then decline, like smoking (Figure 1b). There is now a small but increasing number of people who choose not to own a car or to leave it at home for many journeys. Like smoking, car ownership is also increasing in CEE, Far Eastern and developing countries, as they aspire to a ‘western’ lifestyle. Use of both these products demonstrates aspects of behavioural addiction, although cigarettes, as nicotine-delivery devices, also cause physical addiction.1 Smoking is usually associated with a number of other adverse lifestyles, such as poor diet and lack of exercise.2,3 Those with access to a car walk and cycle less.4
The industry Both the tobacco and the automobile and oil (auto/oil) industries are dominated by a small number of multinational corporations. This gives them political and financial clout, with the power to influence governments. A major difference between the industries is in their responses to awareness of their products’ unwanted effects. The tobacco industry lied,5 promoted dispute,6 paid scientists to muddy the waters7 and have opposed regulation at every step.5 Voluntary restriction and legislation to curb or ban advertising have been fought vigorously. The auto/oil industries have Department of Epidemiology and Public Health, Imperial College, St Mary’s Campus, Norfolk Place, London W2 1PG. Jennifer Mindell, Honorary Clinical Lecturer E-mail:
[email protected]
© Faculty of Public Health Medicine 2001
Respiratory illness in children 5 years30 Asthma admissions Cardiovascular admissions Total
Hospital admissions in non-users p.a.
*Totals may not add up because of rounding. †Source: RCP 2000.1 ‡Assumes average of 32 years of life lost per road traffic death (K. McMahon, personal communication).
Years of life lost before 75
4300 420 365 600 12000 17685
Miscarriages30 Perinatal deaths (stillbirths and early neonatal deaths)30 Sudden Infant Death Syndrome30 Lung cancer 32 CHD32 Total
Deaths p.a. in non-users in the UK
551000†
17219 Speculative Speculative 17219
109000 112000 134000 14100 5700 364200*†
Cancers COPD (84%) and pneumonia (23%) Circulatory diseases (e.g. 30% of CHD, 17% of strokes) Other Admissions prevented by smoking Total (1997–1998)
Hospital admissions in current and former users p.a.
34200 37700 45100 2000 1400 117400*†
COPD (84%) and pneumonia (17%) Cardiovascular diseases (e.g. 17% of CHD, 10% of strokes) Cancers (e.g. 84% of lung cancer) Other Deaths prevented by smoking Net total (1997)
Deaths p.a. in current and former users in the UK
Tobacco industry
Table 1 Burden of disease attributable to the tobacco and auto/oil industries
Road traffic deaths in car users‡ Road traffic deaths in other road users
PM10 and NO2 air pollution31 Serious road traffic injuries 1999 other than car occupants4 Admissions attributable to a sedentary lifestyle in those not allowed or too frightened by traffic to walk or cycle Total
PM10 and NO2 air pollution31 Road traffic deaths 1999 other than car occupants4 Deaths attributable to a sedentary lifestyle in those not allowed or too frightened by traffic to walk or cycle Total
Serious road traffic injuries 1999 – car users4 Heart attacks and strokes attributable to a sedentary lifestyle Total
Road traffic deaths 1999 – car occupants4 Cardiovascular deaths attributable to a sedentary lifestyle (e.g. 50% of CHD, 25% of strokes) Cancer deaths attributable to a sedentary lifestyle Total
Auto/oil industries
~50000 ~55000
Speculative 39641
19200 20441
Speculative 9836
8100 1736
Speculative 18681
18681
Speculative Speculative 1687
1687
92 JOURNAL OF PUBLIC HEALTH MEDICINE
93
LESSONS FROM TOBACCO CONTROL
tomers and governments or has been suppressed. Low-nicotine and low-tar cigarettes were designed to give low readings on machines but the microscopic vent holes (through which air is drawn in to reduce the tar and nicotine levels) are positioned where most smokers automatically block them with their lips or fingers.9 The bio-availability of nicotine has been manipulated.1
accepted regulation, albeit with vigorous negotiations. For example, motor manufacturers are discussing with European regulators to what extent the industry can or should change vehicle design or construction to reduce injuries to pedestrians hit by cars.8 Technology is used by tobacco manufacturers to trick cusTable 2 Smoking and driving by age % Smoking prevalence, 1998
Weekly cigarette consumption per smoker, 1998
% Driving licence holders, 1997–1999
Age
Men
Women
Men
Women
Men
Women
16–19 20–24 25–34 35–49 50–59 60
30 42 37 32 26 15
33 40 33 28 26 16
122 117 108 72 96 91
71 80 85 102 103 84
All Combined
28
46 80 90 91 89 84 64 82
39 69 76 75 67 51 22 59
16–19 20–24 25–34 35–49 50–59 60
26
106
17–20 21–29 30–39 40–49 50–59 60–69 70
91
27
98
70
Sources of data: tobacco use, Ref. 18; driving licence holders, Ref. 4.
Table 3 Smoking and driving by socio-economic group
Professional Managers Intermediate Junior NM Skilled M Semi-skilled M Unskilled M All
% Smoking prevalence, 1998
Weekly cigarette consumption per smoker, 1998
Households with no car 1996 (%)
Men
Women
Men
All
15 21
14 20
91 104
65 85
24
24
98
89
32 37 42 28
29 32 31 26
115 112 120
97 102 100
Women
5 4 15 28 12 33 45 30
106
NM, non-manual; M, manual. Sources of data: tobacco use, Ref. 18; car ownership, Ref. 33.
Table 4 Smoking and drinking by quintile of household income
Highest 4th quintile 3rd quintile 2nd quintile Lowest All
Weekly cigarette expenditure per household 1998–1999 (£)*
Weekly tobacco expenditure per household 1998–1999 (£)*
Distance travelled by car or motorcycle p.a. 1996–1998 (miles)†
Total distance travelled p.a. 1996–1998 (miles)†
All
All
Men
Women
Men
Women
5.05 6.35 6.40 5.05 3.65 5.30
5.55 6.95 6.95 5.65 4.00 5.80
10762 8133 6155 4020 2606 6627
7729 5943 4259 3100 2025 4560
13057 9504 7167 5064 3654 8002
9297 7034 5289 4232 3032 5715
*Data from Family Expenditure Survey 1998–1999, Office for National Statistics. †Data from National Travel Survey 1997–1999 (D. Hird, personal communication).
94
JOURNAL OF PUBLIC HEALTH MEDICINE
Industry knowledge of how to reduce or eliminate some of the most potent carcinogens in tobacco (e.g. nitrosamines) was not used,10 as producing ‘safer’ cigarettes would have been tantamount to a public admission by the industry that existing products were not safe. The auto/oil industries, on the other hand, have embraced the technical fix approach. To decrease air pollution, they have reduced the sulphur and lead content of fuel, developed threeway catalytic converters and particle traps, and agreed more stringent restrictions on emissions from new vehicles. To protect car occupants from injury after a collision, they have introduced airbags and side impact protection. However, the technical fix approach yields far less public health benefit than a broad raft of policies to reduce use. Many smokers with health concerns switched to low-tar or lownicotine cigarettes instead of quitting, but this is often compared with ‘jumping off a four-storey instead of a 10-storey building’. Reduced personal risk for drivers may, through risk compensation, lead to more risk-taking and therefore a higher chance of collision, increasing injuries to other road users. A comprehensive tobacco control strategy aims to increase cessation and reduce uptake of smoking. An integrated transport policy that improves public transport and reduces the volume and speed of traffic brings the benefits of reduced air pollution plus fewer and less serious injuries, less noise and community severance, and increases physical activity, access and equity.
The environment Production Environmental degradation is caused by both industries. Deforestation in tobacco-growing areas occurs to clear land for cultivation but especially to provide wood for curing tobacco. Chemical use of both pesticides and fertilizers is extremely heavy.11 Manufacturing cars is a heavily energy-dependent process.12 Environmental disasters occur when oil spills from damaged pipes or tankers.
Use Tobacco smoke is the commonest cause of indoor air pollution and motor vehicles of outdoor air pollution in more economically developed countries. Road traffic accounts for 34 per cent of the United Kingdom’s energy consumption and is the source of 24 per cent of the United Kingdom’s emissions of carbon dioxide,13 the major contributor to global warming with its potential effects on human health.14 For most of the last half-century, more economically developed countries have been designed for these industries’ customers. Non-smokers have only recently had areas where the right to breathe smoke-free air has superseded people’s wish to smoke. This is still far from universal, with the government blocking the Health and Safety Executive’s Approved Code of Practice.
Figure 1 (a) Trends in car ownership per household. , one or more cars; , two or more cars; , three or more cars. Source of data: Transport statistics Great Britain 2000.4 (b) Trends in cigarette smoking by sex. , male (TAC); , male (GHS); , female (TAC); , female (GHS). Sources of data: TAC (Tobacco Advisory Council);34 GHS (General Household Survey).35
LESSONS FROM TOBACCO CONTROL
Similarly, land-use planning has in most cases assumed car ownership, with poor access for non-car-users.
Disposal A total of 200 million cigarette butts and 20 million packets are discarded in the United Kingdom each day, many onto the ground, accounting for 40 per cent of street litter.15 Every year, eight to nine million vehicles are disposed of in the EU, each one generating a tonne of waste. The metal is recycled but 2 million tonnes are sent to landfill sites as hazardous waste.16
Product promotion Both industries use advertising to sell an image, not reality. Wide-open spaces and mountain scenery distract us from the illhealth and pollution their products cause. The freedom portrayed is in marked contrast to users’ dependence on their products, the number of people killed or harmed by them, and the congestion experienced by most urban motorists. Codes of practice on tobacco and car advertisements have been widely flouted.8,17
Health promotion strategies Over two-thirds of smokers would like to quit.18 This is not true of drivers. The main benefit of private car use is warm, dry,
Figure 1 Continued.
95
door-to-door travel for driver, passengers and luggage, without needing close contact with strangers. Once a car is bought and annual costs are paid, marginal travel costs are extremely small compared with public transport. In the last 25 years, motoring costs have not changed in real terms (1998 index 99.3 relative to 100.0 in 1974), whereas rail and bus fares have increased sharply (rail 150.2; bus and coach 170.8).4 For smokers trying to reduce harm, cutting down seldom works. Those whose consumption does not increase again may save money but as they usually inhale more deeply and leave shorter butts, their nicotine (and tar) intake remains little altered.1,9 Driver behaviour, however, is more likely to be changed by reduction than stopping. Congestion charging, charges for car parking and travel blending,19 where transport patterns are examined to allow access with fewer journeys, are all ways of reducing car use. Control policies for both products are similar: education, encouragement, counter-advertising; fiscal measures; regulation of design; regulation of advertising; technical fixes to reduce emissions; enforcement; legislation; promoting less-harmful options. Education is a necessary prerequisite for the effectiveness of other tobacco control policies but is not very effective by itself, although it is widely advocated by the tobacco industry.20 Measures known to be effective in reducing smoking are actively opposed by tobacco companies.20 There is an equally effective road lobby.
96
JOURNAL OF PUBLIC HEALTH MEDICINE
Minimum ages for being sold tobacco or obtaining a driving licence are designed to protect young people (and, in the case of driving, the general public) from behaviours for which they are too young to make mature decisions or exert control. However, this, in combination with glamorous, witty advertising that associates the activity with success, masculinity or femininity, leads to these ‘adult’ activities having an added desirability and mystique. Where smoke-free areas or car-free days or areas have been introduced, they have usually been well liked, despite initial opposition, and are good for business.21,22 Staff transport policies are at the stage no-smoking policies were 20 years ago: a minority of hospitals and local authorities have them, although they are officially encouraged. Studies have also shown net job creation from reducing cigarette consumption23 or traffic.24 It is unlikely that litigation will be as useful in promoting sustainable transport policies as it has in revealing internal tobacco industry information and challenging the industry’s power.
The future I see two main public health challenges. First, how do we change social attitudes to car use? Media advocacy has been a powerful tool in tobacco control25,26 and in drinking and driving.27 It is time to challenge social norms relating to transport. Why are traffic offences such as speeding not considered by the public or police as a criminal offence with serious consequences? We should confront assumptions that car use is the best way to travel or a right. Fiscal policies cause problems for government when they are not acceptable, as was shown by the fuel protests of 2000. Smokers and drivers feel they pay too much, yet they are unaware of the many externalities (the external costs of transport not paid by private transport users or public transport providers), such as the health and environmental costs to society. We also need to change the language, to frame the issues. Why do politicians and the press talk of ‘investing’ in roads but ‘subsidizing’ public transport? Should the daily 10 deaths on UK roads and 334 from tobacco share media invisibility? Second, how do we change conditions to make ‘the healthy choice the easy choice’? Governments can encourage substitutes for cigarette or cars by, for example, making nicotine replacement therapy more readily available or improving bus services. The White Papers on Tobacco Control and an Integrated Transport Strategy were warmly welcomed for their broad raft of measures but we still await delivery. Powerful industry lobbies can prevent or dilute legislation that they believe will harm their profits,28 and negotiated agreements have proved of little use in tobacco control.29 British doctors, subjects of Doll and Bradford-Hill’s cohort study, were the first group to stop smoking. The Royal College of Physicians of London and the British Medical Association initiated campaigning for tobacco control; banning tobacco advertising has been a slow process but is now accepted policy in the United Kingdom. Tobacco control has shown that collab-
oration by national and international networks of healthcare professionals, voluntary organizations, charities and their supporters can match the political power of these industries. As with smoking, we need to lead by example in both our personal behaviour and our professional roles.
Acknowledgements I thank Judith Cohen, Drew Hird, Laura Radiconcini and Amanda Sandford for supplying data, and Amanda Sandford and Dr David Cohen for helpful comments on an earlier draft of this paper.
References 1 Tobacco Advisory Group of The Royal College of Physicians. Nicotine addiction in Britain. London: RCP, 2000. 2 Shi L. Sociodemographic characteristics and individual health behaviors. South Med J 1998; 91: 933–941. 3 Burke V, Milligan RA, Beilin LJ, et al. Clustering of health-related behaviors among 18-year-old Australians. Prev Med 1997; 26: 724–733. 4 Department of the Environment, Transport and the Regions. Transport statistics Great Britain: 2000 Edition. London: TSO, 2000. 5 Action on Smoking and Health. Tobacco explained – the truth about the tobacco industry in its own words. 1998. London, ASH. [On-line.] http://www.ash.org.uk/html/conduct/html/tobexpld0.html (28 March 2001, date last accessed). 6 House of Commons Health Select Committee. Second report. The tobacco industry and the health risks of smoking. London: The Stationery Office, 2000. 7 Boyse S. [On-line.] http://www.gate.net/~jcannon/documents/880217b1.txt (22 January 2001, date last accessed). 8 Department of the Environment, Transport and the Regions. Tomorrow’s roads – safer for everyone. The government’s road safety strategy and casualty reduction targets for 2010. London: DETR, 2000. 9 Jarvis MJ, Bates C. Why low tar cigarettes don’t work and how the tobacco industry has fooled the smoking public. London: ASH, 1999. [On-line.] http://www.ash.org.uk/html/regulation/html/big-one.html (28 March 2001, last date accessed). 10 ASH, ICRF. The safer cigarette: What the tobacco industry could do and why it hasn’t done it. London: ASH, 1999. [On-line.] http://www.ash.org.uk/html/regulation/html/patent.html (28 March 2001, date last accessed). 11 Action on Smoking and Health. Tobacco & the environment. Factsheet 22. London: ASH, 1998. [On-line.] www.ash.org.uk/html/factsheets/html/fact22.html (28 March 2001, date last accessed). 12 Amici della Terra. The environment and social costs of transport in Italy: production, use and disposal of vehicles. Third report. Rome: Amici della Terra, 2000. 13 Department of the Environment, Transport and the Regions. Digest of environmental statistics no. 21, 1999. London: TSO, 1999. 14 McMichael AJ, Haines A. Global climate change: the potential effects on health. Br Med J 1997; 315: 805–809. 15 Inkpen. Litterbug report. London: Tidy Britain Group, 1995. 16 Friends of the Earth. Car recycling gets EU green light. [On-line.]
LESSONS FROM TOBACCO CONTROL http://www.foe.co.uk/pubsinfo/infoteam/pressrel/2000/200002031404 48.html (3 February 2000, date last accessed). 17 Mindell JS. The UK voluntary agreement on tobacco advertising: a comatose policy? Tobacco Control 1993; 2: 209–214. 18 National Statistics, Department of Health. Statistics on smoking: England, 1978 onwards. London: TSO, 2001. [On-line.] http://www.doh.gov.uk/pdfs/sb0017.pdf (28 March 2001, date last accessed). 19 Ampt E. Grass routes: from travel blending to living neighbourhoods. tec October 1999; 475–478. 20 Bates C, Watkins P, McNeill A. Danger! PR in the playground. Tobacco industry initiatives on youth smoking. London: Cancer Research Campaign and Action on Smoking and Health, 2000. [On-line.] http://www.ash.org.uk/html/advspo/html/playground.html (28 March 2001, date last accessed). 21 Chapman S. Smoking in public places. Br Med J 1996; 312: 1051–1052. 22 Environmental Transport Association. Car free day. Going Green Issue 37 Winter 2000; 8–9. [On-line.] http://www.eta.co.uk/pr/gg/gg37/ g3708.htm (28 March 2001, date last accessed). 23 Buck D, Godfrey C, Raw M, Sutton M. Tobacco and jobs. York: Centre for Health Economics, University of York, 1995. 24 Jenkins C. Less traffic, more jobs. London: Friends of the Earth Trust, 1997. [On-line.] http://www.foe.co.uk/campaigns/atmosphere_and_ transport/pdf/ltmj.pdf (28 March 2001, date last accessed). 25 Reid DJ, Killoran AJ, McNeill AD, Chambers JS. Choosing the most effective health promotion options for reducing a nation’s smoking prevalence. Tobacco Control 1992; 1: 185–197.
97
26 Chapman S, Lupton D. The fight for public health: principles and practice of media advocacy. London: BMJ Publishing Group, 1994. 27 Russell A, Voas RB, Dejong W, Chaloupa M. MADD rates the states: a media advocacy event to advance the agenda against alcohol-impaired driving. Public Hlth Rep 1995; 110: 240–245. 28 Report of the Committee of Experts on Tobacco Industry Documents. Tobacco company strategies to undermine tobacco control activities at the World Health Organization. Geneva: World Health Organization, 2000. 29 Daube M. Voluntary agreements: designed to fail. Tobacco Control 1993; 2: 183–184. 30 Royal College of Physicians of London. Smoking and the young. London: RCP, 1992. 31 Department of Health Committee on the Medical Effects of Air Pollutants. Quantification of the effects of air pollution on health in the United Kingdom. London: HMSO, 1998. 32 Action on Smoking and Health. Passive smoking. London: ASH, 1998. [On-line.] http://www.ash.org.uk/html/factsheets/html/ fact08.html (28 March 2001, date last accessed). 33 Davis A. Inequalities of health: road transport and pollution. In: Gordon D, Shaw M, Dorling D, Davey Smith G, eds. Inequalities in health: the evidence. Bristol: Policy Press, 1999: 170–184. 34 Wald N, Nicolaides-Bouman A. UK smoking statistics. London: OUP, 1991. 35 Office for National Statistics. Living in Britain. Results from the General Household Survey 1998. London: TSO, 2000.
Accepted on 5 February 2001
