Despite recent progress in limiting tobacco advertising and usage in the United States,1 the tobacco industry is rapidly expanding into larger global markets. While smoking prevalence rates have decreased 1% per year in Western countries since the mid-1970s, tobacco use has surged in the developing world.2 Worldwide estimates indicate that annual deaths from cigarette smoking will rise from the current figure of 3 million to 10 million by 2025, with approximately 70% of these deaths occurring in developing countries.3 The disparity is alarming. Medical students and physicians have a unique opportunity to make known the individual and societal consequences of tobacco marketing overseas4,5 and to thereby minimize smoking-related morbidity and mortality.
Several aspects of international tobacco marketing are cause for concern. Tobacco companies are promoting and marketing overseas in ways long banned in the United States, for instance, selling cigarettes without a health warning label and advertising on television. Outside the United States, the tobacco industry sponsors high-school sporting events, distributes free cigarette samples, and even arranges for discotheques to grant free admission in exchange for empty cartons of cigarettes.6,7 Further, studies show that cigarettes sold in the Philippines have 50% more tar content and as much as twice the amount of nicotine as those sold by the same companies in the United States.8
China, with a population of 1.1 billion, is the largest tobacco market in the world. The potential earnings from the lifetime tobacco addiction of a large population are strong incentives for the industry to target Asia. As in many developing countries, the US industry is not only outperforming local tobacco companies in China, but it is also replacing unsophisticated, often rural, indigenous tobacco businesses that generally do not advertise aggressively.9,10
Current US law encourages the foreign practices of American tobacco companies. Section 301 amendment of the 1974 Trade Act has essentially opened the door for tobacco companies in Asian markets by giving the executive branch of government the authority to threaten trade sanctions against any country that impedes the sale of US tobacco products.11 In 1987 and 1988, the US government threatened to impose trade sanctions 3 times. In response, Japan and Korea began allowing US cigarette imports without tariffs. Television advertisements in Japan increased 10-fold.6 Japan's public health lobby stated that this "saturation advertising" targeted women and adolescents, despite solemn assurances from industry officials that they would not do so.12 Within a few years, US cigarette imports to Japan increased 75% with predictably sharp increases in smoking, especially among Japanese women and adolescents.7
It is precisely these types of activities that have recently motivated individuals and institutions to stand against smoking by divesting tobacco stocks. In 1990 at Harvard University, a group of students in a public health class inquired about the institution's investment portfolio. Once the students learned of the school's ownership of tobacco stocks, they wrote letters to the university president stating the discrepancy between the medical and public health schools' mission to promote health and its tobacco investments. Within one year, Harvard University sold over $58 million worth of stocks in tobacco companies, namely, American Brands, Philip Morris, British American Tobacco, and US Tobacco.13 In announcing the divestment to Harvard students, the university president stated in a letter (May 18, 1990) that the decision was made because of "the health hazards of smoking and the vigorous and successful efforts of companies to promote sales of cigarettes to teenagers and to inhabitants of countries where no warnings are required."
The Harvard experience is encouraging, and there are many more opportunities for medical students and health care professionals to take a stand against the tobacco industry. For example, in 1995 a report in the Lancet showed that many health maintenance organizations own a substantial share of tobacco companies. The Prudential Insurance Company, which was the largest health insurer in the United States in 1995, was reported to own at least $248 million in tobacco investments.14 Months after this fact was publicized, Prudential sold its tobacco stocks.
Medical students can protest the recent surge of international tobacco marketing in several ways. First, students should request a list of holdings in their institution's endowment portfolio, and insist on an institutional ban on tobacco investments by writing to their university president and business managers. Second, students can stand against the industry by voicing concern to their institutional investment responsibility committee and requesting medical student representation on the committee.
Finally, students should urge Congress to repeal Section 301 of the 1974 Trade Act, which unfairly protects the US tobacco industry. In addition, students should challenge the US government's permissive policies on unrestricted marketing and sale of a more addictive and more hazardous cigarettes than those marketed and sold at home. At minimum, US tobacco companies and their subsidiaries should adhere to the same standards of product marketing, promotion, and sales that are required in their home country.
It is predicted that tobacco poses the greatest future health risk to the developing world, surpassing malnutrition and communicable diseases. Student efforts advocating divestment of tobacco stocks and legislative reform are crucial in stemming the tide of smoking worldwide.
Martin A. Makary, Ichiro Kawachi. The International Tobacco Strategy. JAMA. 1998;280(13):1194–1195. doi:10.1001/jama.280.13.1194-JMS1007-5-1