WORK A Journal of Prevention,

Assessment & Rehabilitation

ELSEVIER

Work 11 (1998) 107-117

Global health issues

The global effects of the tobacco industry Nancy J. Murdock, Donna Mcivor Joss* Worcester State College, Occupational Therapy Department, 486 Chandler Street, Worcester, MA 01602, USA

Abstract The politics, economics, health impacts, and regulation of the tobacco industry are common themes in recent debates. This paper documents worldwide impacts of tobacco use, including the health implications as well as the politics and economics of tobacco regulation. A review of the proposed settlement and potential legislation is presented. Methods of occupational therapy intervention are also discussed. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Tobacco industry; Tobacco regulation; Economics of tobacco; Occupational therapy

1. The tobacco industry

this paper is to:

King James I of England said that tobacco was 'loathsome to the eye, hateful to the nose, harmful to the brain' and 'dangerous to the lungs' (McGrew, 1996: 1). King James was neither the first nor the last person to oppose the use of tobacco. Since his time, tobacco has developed into a large and profitable industry throughout the world and has always been the subject of much scrutiny and controversy. Health, political, economic, and regulatory issues have long been the subjects of debate surrounding the tobacco industry. The purpose of

• • • • • •

discuss tobacco consumption throughout the world; explain the health implications of the use of tobacco products; explore the economics of the tobacco industry; discuss the political implications of the tobacco industry; explain tobacco regulation throughout the world; introduce the proposed tobacco settlement and possible legislation which could result from it.

2. Tobacco consumption throughout the world

* Corresponding author. Tel.: + 1 508 9298119; fax: + 1 508

7938184

There are many different ways in which to-

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bacco can be used. The way in which it is used depends largely on the cultural and social values placed on tobacco use. The most common device for tobacco use is the cigarette. These can be either manufactured by cigarette companies or rolled by the smoker. A form of cigarette that is common in India and Bangladesh is the bidi. Bidis consist of tobacco rolled in temburni leaf. Cigars and pipes are other well-known methods of smoking tobacco. Egyptians often use a water pipe called a hookah or shisha to smoke tobacco. There are also several forms of smokeless tobacco which are popular throughout the world. Some of these include chewing tobacco, betel quid, and nasal or oral snuff (World Health Organization, 1996a). The World Health Organization (1996b) estimates that there are 1.1 billion smokers in the world. This is approximately one-third of the world population over 15 years of age. Although tobacco consumption in the United States and other industrialized countries has declined over the past few years, the global rate of consumption is on the rise due to increases in the number of users in developing countries. The current rate of smoking goes up 3% each year in developing countries (Bartecchi et al., 1995). There is an expected increase in the number of negative health impacts in developing countries, partly because cigarettes low in tar and nicotine are relatively unknown in many developing nations (Barry, 1991). Although the US has experienced a significant decline in the number of smokers over the past 30 years, there are still many people that use tobacco products. In the United States 22.4% of people smoke (World Health Organization, 1997). An additional 7.5 million use smokeless tobacco (Bartecchi et al., 1995). The number of US smokers has significantly declined since the report of the Surgeon General Advisory Committee in 1964 (Barry, 1991). China is experiencing a large increase in the number of smokers. China is now the largest producer and consumer of tobacco in the world (World Health Organization, 1997). There are currently 300 million smokers in China. This makes up 30% of the world's smoking population.

Sixty-one percent of Chinese men and 7% of Chinese women smoke (Tyler, 1996). The relative price of cigarettes in China is very expensive as well. In 1990, it was estimated that a pack of 20 cigarettes costs approximately 25% of the average daily income (World Health Organization, 1997). Other regions are experiencing an increase in tobacco consumption as well. In Eastern Europe, where smoking is socially acceptable, there is a very high rate of smokers (Hillmore, 1994). As many as 55-70% of men and 30-35% of women smoke in Eastern Europe (Patel, 1994). The number of cigarettes smoked in India increased 400% between 1960 and 1980. There was a 300% increase in Papua New Guinea in the same time period (Barry, 1991). Statistics show that 47% of the people in Denmark smoke regularly (Smokers' paradise, 1994). African countries have also experienced large increases in the number of tobacco users. Yach (1996) believes that this is due to a combination of urbanization, westernization, and an increase in disposable income in many African countries. Smokeless tobacco has proven to be popular among certain ethnic groups in Africa. In Kenya 75% of the Maasai, 88% of the Samburu, and 67% of the Luo women were found to use smokeless tobacco (World Health Organization, 1997). Because of the large and growing consumption of tobacco, there are increasing health consequences being observed. 3. Health effects of tobacco use Native Americans once used tobacco for medicinal purposes. They believed it would alleviate aches and pains, snake bites, stomach and chest pains, chills, fatigue, hunger, and thirst. In the sixteenth century, many Europeans also believed that tobacco could cure aches and pains as well as diseases of the lung and chest (Ravenholt, 1990). Although the tobacco industry claims that smoking does not cause health problems (Gibson, 1997), there is much evidence to dispute their claim. Smoking causes heart disease, cerebral vascular accidents, peripheral vascular disease, chronic obstructive pulmonary disease, and low birth-

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weight babies. Smoking also causes cancers of the oral cavity, esophagus, and lungs. Unsuccessful pregnancies and infant mortalities may also be due to a mother's smoking. Women experience the same tobacco-related illnesses as men but there are a few gender specific effects of smoking. Women who smoke have increased risks of cervical cancer, premature menopause, and impaired fertility (World Health Organization, 1996c). Due to the enormous numbers of illnesses and deaths associated with tobacco use, Ravenholt (1990) has described tobacco as a plague, named tobaccosis. Widespread tobacco use and its negative health impact have also been referred to as a global epidemic (Bartecchi et aI., 1995). Worldwide, smoking kills 3 million people annually (Mackay, 1994) and this number could increase to 10 million by 2020 or 2030. Seventy percent of these deaths are expected to occur in developing countries. If the rate of cigarette consumption continues at the current rate, there will be 2-3 million tobacco-related deaths in China alone by the year 2020 (World Health Organization, 1996a). It is estimated that cigarette smoking will lead to 21 million deaths in the 1990s in industrialized countries alone (Ravenholt, 1990). Half of all lifelong smokers will die from tobacco-related illnesses, and half of these people will die before age 70 (World Health Organization, 1996b). Figures suggest that each cigarette an individual smokes takes 5.5 min off of his or her life (Bartecchi et aI., 1995). In the United States alone, tobacco causes 434000 deaths each year (Gibson, 1997). Although lung cancer causes 112000 deaths in America each year, the number of strokes, aneurysms, and other cardiovascular diseases double the number of deaths from lung cancer (Brown and Kane, 1993). Smoking is not only dangerous to those who use these tobacco products. Environmental Tobacco Smoke (ETS) or second hand smoke poses a severe health risk to those who are exposed to smoking. Thirty-seven percent of non-smoking adults in the US are exposed to second hand smoke either at home or at work. Some of the diagnoses for non-smokers exposed to ETS are lung cancer, asthma, respiratory infection, de-

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creased pulmonary function, and cardiovascular disease (Pirkle et aI., 1996). In the United States alone, 50000 deaths each year are a direct result of illnesses from ETS (Gibson, 1997). Children are often exposed to second hand smoke in their homes. Forty-three percent of US children are exposed to ETS by a family member (Pirkle et at, 1996). At least 6200 children in the United States die each year as a result of their parents' smoking. These deaths are a result of low birthweight babies, sudden infant death syndrome (SIDS), lung infections and burns (Coleman, 1997). An additional 5.4 million children in the US suffer from illnesses, such as ear infections and asthma as a result of exposure to ETS. In Bangladesh, the rate of perinatal mortality is 27% for smoking mothers. This is twice the mortality rate for non-smoking mothers (Brown and Kane, 1993). Another group that experiences health problems as a result of tobacco consumption is often overlooked. These are the people that manufacture the tobacco products. Two chemicals that are commonly used in fumigating seedbeds are methyl bromide and ethylene dibromide. Although it is illegal to use ethylene dibromide in the United States, many other countries still use it. Ethylene dibromide can cause a range of health problems from irritation of the eyes, nose, and throat, to liver and kidney damage. The use of this extremely dangerous chemical creates a potential health risk for those who work in the tobacco industry (Yach, 1996). The question must be raised: with all of these negative health effects from smoking, why do people continue to smoke? This brings up an ongoing debate about the addictive properties of nicotine. The tobacco industry insists that nicotine is not an addictive drug. They state that people continue to smoke out of habit, not addiction (Palefreman, 1994). Perhaps it would help to explore what happens when someone inhales a cigarette. Upon inhalation, nicotine attaches to tiny drops of tar and enters the lungs. The smoker experiences a physical reaction only 30 s after taking a puff. These physical reactions include: increase in heart rate and blood pressure, slowing of peripheral blood

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flow, and decrease in skin temperature. Hormones are released that affect the central nervous system and brain waves change (Ravenholt, 1990). The changes in the central nervous system and brain may be clues to explain the addictive nature of nicotine. There are 46 million smokers in the United States. Approximately 70% of these smokers would like to stop but less than 3% are able to refrain from smoking for a I-year period (Heishman et aI., 1997). In 1988 the US Surgeon General made three conclusions about tobacco: • • •

cigarettes and other tobacco products are addictive; tobacco products are addictive because they contain the addictive drug nicotine; there are chemical and behavioral processes which are used to determine the addictiveness of nicotine which are similar to the processes that determine the addictiveness of cocaine and heroin (Heishman et aI., 1997).

Adults that regularly smoke are likely to develop this nicotine addiction in adolescence. Eighty-two percent of all adults who smoke, smoked their first cigarette before they turned eighteen (Bartecchi et aI., 1995). What can smokers do to stop smoking? There are many smoking cessation devices on the market now. Most of these products contain nicotine to stop cravings without smoking. This is referred to as nicotine replacement therapy. The nicotine patch and nicotine gum are available in the US over the counter. Both of these supply a controlled amount of nicotine to the body without the hazards of inhaling cigarette smoke. There is also a prescription nasal spray that is available to relieve nicotine cravings. All of these products are designed to gradually decrease the amount of nicotine a smoker receives until he or she is no longer dependent on it (The Hearst Corporation, 1996). There are several interventions that do not involve nicotine that have proven successful in smoking cessation. Some smokers turn to hypnosis, acupuncture, or support groups to help them quit smoking (The Hearst Corporation, 1996).

There are a variety of smoking cessation programs available to those who wish to stop smoking. Possibly the most important intervention pertaining to tobacco and health is education. Many of these health problems would not exist if people were warned of the risks of smoking and never started the habit. Several countries have educational plans designed to decrease the number of smokers. In the US, the Centers for Disease Control and Prevention run media campaigns about the dangers of smoking. Cuba has required an anti-tobacco curriculum in grade schools. Australia recently allocated $2.3 million to develop a campaign designed to keep young people from smoking. Not all countries have the resources to implement such programs. Zimbabwe, for example, has no sustained health education campaigns related to tobacco (World Health Organization, 1997). 4. Economics of the tobacco industry

There are many aspects of the economics of the tobacco industry. The tobacco industry benefits national economies through employment and the tax revenue generated. Economic burdens caused by the tobacco industry include: health care costs, lost productivity, loss of land that could be used to grow food, environmental costs, as well as costs to the individual smoker (Mackay, 1994). The production and consumption of tobacco products influences economies throughout the world. The tobacco industry employs millions of people worldwide. People are employed in farming tobacco, manufacturing tobacco products, and selling tobacco products. The Chinese Tobacco Corporation alone employs over 500000 people in manufacturing, 10 million farmers growing tobacco leaf, and 13 million retailers (Skolnick, 1996). Tobacco is a major employer in Africa. It is the most widely grown non-food product in African countries. In 1993, the US Department of Agriculture reported that 500000 tons of tobacco were produced by 33 African countries (Yach, 1996). Tobacco is one of Zimbabwe's largest employers

N.J. Murdock, D. McIvor Joss

and their largest export (Lighting up the third world, 1994). In the United States, the tobacco industry employed over 100000 people in tobacco manufacturing. These workers earned $500 million in wages. There were 3 million people from 750000 families employed in the cultivation of tobacco earning $1.4 billion for their work. There are 4500 wholesalers that distribute tobacco products and hundreds of thousands of merchants that receive income from the sale of tobacco (McGrew, 1996). In this sense, tobacco companies contribute greatly to the economy. The tobacco industl)' claims that increased restrictions on their products could result in loss of employment and therefore hurt the economy. Warner et al. (1996) conducted a study to see what would happen if tobacco production in the US decreased. They concluded that the money formerly spent on tobacco products would not disappear. Instead, it would be put back into other industries, thus creating more jobs in different businesses. They concluded that there would actually be an increase in jobs in nontobacco states and only a slight decrease in employment in tobacco-producing states. Overall, there would be a small increase in the number of jobs nationwide. The tobacco industry can benefit a nation's economy through the revenue gained by taxing tobacco products. In the US, tobacco taxes val)' from state to state. The range is 20-44%. Considering the average price of cigarettes in the US is $1.89 (World Health Organization, 1997), taxes on each pack would range from $0.38 to $0.83 for each pack. Taxes in the US are relatively low compared to other countries. Denmark, Norway, and Canada all have taxes over $3.00 per pack. Sweden, the UK, and Germany's taxes range between $2.00 and $3.00 for each pack of cigarettes (Brown and Kane, 1993). In China there is a 420% tax on the selling price of cigarettes (Dean, 1995). In 1992, tobacco taxes in China drew in $5 billion or 10% of all revenue (Skolnick, 1996). Raising the taxes on cigarettes may be an incentive for some to stop smoking and for others not to start. When Canada raised taxes dramati-

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cally, they found large decreases in the number of smokers. Teen smoking was lowered by 2/3 and the number of adult smokers was cut in half. There were similar results in New Zealand. When New Zealand nearly doubled the price of a pack of cigarettes, consumption of cigarettes decreased by 50% (Ravenholt, 1990). Although the taxes on· tobacco products contribute a great deal of money to a nation's economy, this is offset by the cost of health care for those that smoke. Public health officials support cigarette taxes for two reasons: • •

to fund government spending for health care costs from tobacco-related diseases. to increase taxes in order to reduce the number of smokers, therefore reducing the number of tobacco-related diseases. Workers who are healthier take less sick leave and are more productive and competitive (Brown and Kane, 1993).

In the US health care system, insurance companies pay for the care of those who have tobacco-related illnesses while Medicare and Medicaid pay for those that have no insurance. These expenses are then passed on to the public in the form of higher health care costs for everyone (Gibson, 1997). In an opposing view, Gladwell (1990) states that smokers are actually saving the government money. Even though they run up large health bills, smokers die young, thus not using up their social security. Because of the young age at which smokers die, they may still have their own insurance for medical bills rather than relying on Medicare (Gladwell, 1990). Other countries are also having difficulties paying for the health care of tobacco-related diseases. In 1993, the global health care cost of smoking-related diseases was $50 billion. This averages out to $2.06 for each pack of cigarettes sold (Bartecchi et at, 1995). For example, Africa is having problems fighting tobacco-related diseases. African countries are still struggling with the diseases of poverty, such as tuberculosis, measles, malaria, tl)'panosomiasis, and cholera. The increase in tobacco consumption is draining

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the few available resources in those countries to pay for tobacco-related illnesses (Yach, 1996). Not only do tobacco users cost more in health care, they cost their employers as well. Smokers take more sick days than do non-smoking employees. Employers also receive less productivity from their smoking employees than non-smoking employees do (Gibson, 1997). The tobacco industry influences third world countries in a unique way. Tobacco is grown in place of food, which is desperately needed in many developing nations. There are 4.3 million hectares of the earth's surface that are devoted to growing tobacco. Seventy-two percent of this land is in developing nations. Tobacco is grown in place of crops that could be used to fight the widespread hunger in these nations (Ravenholt, 1990). If all tobacco was replaced with food crops, there would be enough food to feed 10-20 million people (Walker, 1996). As mentioned previously, the consumption rate of tobacco is growing in developing countries. Between 1975 and 1995, there was a 50% increase in global tobacco consumption. Most of this increase has occurred in developing countries where many of the people cannot afford to eat, nonetheless use tobacco products (McLellan, 1994). A study done in Bangladesh found that for the price of 5 cigarettes per day, a poor household is deprived of approximately 8000 calories of nutrition (Walker, 1996). The environment pays a price for tobacco production. It requires one acre of forest to cure one acre of tobacco. Malawi has sacrificed a third of its trees for this purpose (Barry, 1991). Deforestation is also occurring in Tanzania. Over the past 50 years Tanzania has lost 50% of its trees, partly because of tobacco (Yach, 1996). The cultivation of tobacco requires pesticides, fertilizers, and herbicides, which can be harmful to the earth and those that inhabit it (Barry, 1991). As well as increased taxes, there are other economic penalties which have been brought upon the tobacco industry. The World Bank has required that health sector work in Mrica include anti-tobacco activities. The World Bank is prohibited from lending for the production, processing, importation, or marketing of tobacco or tobacco

products (Yach, 1996). Additionally, the American Medical Association has taken a stand against the tobacco industry. On April 23, 1996, the AMA called upon health care and related institutions to sell off their stocks in 13 companies that manufacture tobacco products. It also called upon these institutions to relinquish their ownership of 1474 mutual funds that have partial ownership of tobacco companies (Kinder et aI., 1996). 5. Politics and the tobacco industry The tobacco industry is very interested in what legislation is handed down from the Congress in the United States. The regulations passed in the US affect many other countries as well. There are several ways in which the tobacco industry has power in Congress: The Tobacco Institute and other lobbying groups and donations to congressmen from tobacco growing states. The Tobacco Institute, founded in 1958, represents the tobacco industry'S interests. It is funded by contributions from tobacco companies. The Tobacco Institute reports the pro-tobacco side of the medical debate and tries to discredit antismoking pUblicity. It publishes information about the historical role of tobacco, its place in the national economy, the industry itself, and the public's use of tobacco products (McGrew, 1996). The Tobacco Institute is an extremely powerful lobbying group in the United States and many other countries have a Tobacco Institute which performs a similar function. In the 1920s, 1950s, and 1960s, congress tried to enact legislation to control tobacco. All of these attempts were unsuccessful because of powerful congressmen from the tobacco growing states (Arno et aI., 1996). When the Food and Drug Administration initially proposed their new regulations, six bills were submitted to weaken or prohibit the power that the FDA would have over the tobacco industry. All of these bills were put forth by Congressmen from tobacco-growing states and their political allies (Arno et aI., 1996). Another way that the tobacco industry has political power in the US is through donations to members of congress or to political parties. Moore et ai. (1994) found that there was a direct correla-

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tion between the amount of money a congressman received and the likeliness that he or she would not support tobacco control legislation. After the FDA proposed its tobacco control measures in 1995, the tobacco industry gave $1.5 million to the Republican party. This was five times as much as the Republican party had received for the 2 years previous from the tobacco indu!\try (Arno et al., 1996). From January, 1995 through June 1996, Republicans received $4 million from tobacco companies while Democrats received only $746,000 (Wadman, 1996). Wadman (1996) claims that this is because Republicans try to relax restrictions on tobacco. In 1996, a record $9.9 million was given to congress by the tobacco industry (Common Cause, 1997). The United States politics impact other countries as well. When regulations in the US become strict, tobacco companies go overseas to countries where there is little or no tobacco-control. At one point, the US tobacco companies persuaded the American government to threaten trade sanctions against certain countries if they did not allow the sales and promotion of foreign tobacco products in their countries. These countries included the Republic of Korea, Taiwan, Japan, and Thailand. This statement was made despite the fact that in some of these countries advertising tobacco products is prohibited (Mackay, 1994).

products because of the risks to the general public. There are risks to public health and safety, risks assumed by consenting adults, and risks assumed by children and adolescents. Although the discovery of tobacco occurred hundreds of years ago, most of the restrictions that apply to tobacco products have come about during the past thirty years. The United States was among the first countries to put restrictions on the tobacco industry. In 1966, the Federal Trade Commission required that all packages of cigarettes contain warning labels and that cigarette advertising could not be aimed at people younger than 25. In 1971, television and radio advertising of tobacco products was banned. Many other countries followed the United States with these restrictions. By 1986, 55 countries had placed restrictions on advertising of tobacco (Bartecchi et aI., 1995). In the United States, control of tobacco products now falls under the authority of the Food and Drug Administration. The FDA is able to regulate tobacco under the Food, Drug and Cosmetics Act by declaring the nicotine in tobacco products to be a drug (Kessler et aI., 1996). The most recent restrictions put on tobacco products in the US include prohibition of: •

6. Tobacco regulation • Tobacco has long been a controversial topic when it comes to regulation. In 1629, the Massachusetts Bay settlers were prohibited from planting tobacco except in very small quantities for medicinal purposes (McGrew, 1996). Although these early controls may be the strictest ever put on tobacco, tobacco companies are resisting today's governmental regulations. There are different types of restrictions that are placed on the tobacco industry. Depending on the country, tobacco could face regulations concerning advertising, labeling, tar and nicotine content, importing and exporting, age requirements for purchasing products, and where use of products is permitted. Arno et al. (1996) state that governments can justify regulation of tobacco

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• • •

sale of tobacco products to anyone under the age of 18, requiring a picture identification for anyone under 26 years of age; tobacco vending machines or self-service displays except in places where minors are not permitted (nightclubs, bars, etc.); free samples of tobacco products; outdoor advertising within 1000 feet of schools or playgrounds; and selling or distributing promotional items which show the brand name or logo of a tobacco product. Only corporate names are permitted on these promotional products (Kessler et aI., 1996).

In other countries the restrictions are not as strict. In Japan, some health warnings on boxes of cigarettes read 'It is feared that smoking may harm your health. Please refrain from smoking too much' (Hindell, 1997). Although Japan cur-

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rently allows advertising on radio, television, newspapers, and magazines (World Health Organization, 1997), effective in April 1998, Japanese tobacco companies have agreed to a voluntary advertising ban in an effort to stop widespread smoking among teenagers. Japan has stopped distribution of free samples of tobacco products so that people are not encouraged to begin an addictive behavior (Hindell, 1997). In many countries, there are age restrictions on purchasing tobacco products. The reasoning behind this is that nicotine addiction generally occurs when tobacco users are adolescents (Heishman et aI., 1997). The enforcement of these laws does not necessarily mean that minors are unable to obtain tobacco products. Rigotti et aI. (1997) found that even when merchants complied with these laws minors reported only a small drop in their ability to purchase tobacco and no decline in its consumption. There is a wide range of laws concerning tobacco products and their use. Many countries have laws about advertising, sale to minors, and smoking in public places but there are notable exceptions to this trend: while France has total bans on advertising, there are no laws restricting the sale of tobacco to minors. Sweden also has no laws about selling these products to minors. In the United Kingdom, there is no legislation to ban smoking in public places. Australia has a total ban on all chewing tobacco and oral snuff. In Kenya, there is no legislation about selling tobacco products to children or advertising (World Health Organization, 1997). Many developing countries have even fewer laws concerning the production, sale, and advertising of tobacco products. The major tobacco companies of the US and Britain are taking advantage of this lack of restrictions. In these developing countries, the companies can sell cigarettes without a health warning, advertise on television, and sell at a higher tar content (Mackay, 1994). The US imposes no restrictions of the labeling, tar content, or advertisement of tobacco products that are exported to other countries (Bartecchi et aI., 1995). Because many African countries fall into the category of developing countries with few restric-

tions, the Tobacco Control Commission for Africa was set up with the following objectives: • • • • •

education of advocates for tobacco control; identification and funding for research needed in relation to tobacco control; consultation for governments in relation to tobacco control policies; provision of information to tobacco control groups on a regular basis; and development of ways to fund the Tobacco Control Commission (Yach, 1996).

There are many reasons why such regulations exist. Advertising may have the most restrictions on it worldwide. Tobacco companies spend $4 billion each year on advertising (Pollay, 1997). This makes tobacco products the most heavily marketed consumer item in the US other than automobiles (Altman et aI., 1996). The tobacco industry claims that it does not want its advertising to influence people to use their products, it only wants to influence those that already use them to change to a new brand (Pollay, 1997). Research indicates that this is not the case. Pierce and Gilpin (1995) discovered that each time a particular gender group was targeted in advertising campaigns, the rate of smoking uptake increased in that group. In Hong Kong, where only 1% of the women smoke, the tobacco industry has recently launched a large advertising campaign targeting women, in the hopes of creating a new market (Bartecchi et aI., 1995). In many African countries, the lack of legislative controls and high levels of illiteracy make people more vulnerable to such sales efforts (Yach, 1996). Advertising of tobacco products aimed at children is a subject of much dispute. Although the industry claims that advertising of tobacco products does not influence children, it has been found that 90% of 6-year-olds could correctly match R.J. Reynold's 'Joe Camel' character with cigarettes. Studies also show that teenagers are three times as responsive to cigarette advertising as adults are (Pollay, 1997). Haley Kan, Executive Director of the Tobacco Institute of Hong Kong claims that advertising bans in Singapore are not stopping young people from smoking. The Singa-

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pore Health Ministry reports that the smoking rate for 18 and 19 year olds increased from 9% in 1984 to 12% in 1995, despite bans on advertising (Kan, 1997). Sponsorship and promotional items are another way that tobacco companies advertise to children. About half of all smoking adolescents and a quarter of all non-smoking adolescents own a promotional item (Kessler et al., 1996). To counteract the emphasis on sponsorship, China recently enacted legislation that cigarette brand names are no longer allowed to appear as sponsors at sports or cultural events (Cheung, 1997). 7. Proposed tobacco settlement This paper has described the existing legislation concerning the tobacco industry, but the United States Congress may soon be making changes to the current regulations. On June 20, 1997, the state attorneys general and tobacco companies came to an agreement that could change the way tobacco products are advertised, sold and regulated. If Congress passes this settlement, there would be changes to the economics and the regulations concerning the tobacco industry. The proposed settlement states that the tobacco companies will pay $368.5 billion, mostly to compensate states for health care costs related to smoking. There would also be $60 billion in punitive damages because of the tobacco industry's failure to expose the risks of smoking (Smolowe, 1997). The Food and Drug Administration would gain more power in the regulation of tobacco products. They would have the authority to completely ban tobacco 12 years after passage of the settlement, if they saw fit. The tobacco industry would be responsible for putting stronger warning labels on cigarettes and disclosing the ingredients of cigarettes (Smolowe, 1997). The settlement begins to address the problems of youth smoking. The tobacco industry would fund anti-smoking education campaigns, especially targeted at America's youth. If the number of smokers under 18 did not decrease by 30% within 5 years, the industry would face severe

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fines. The ultimate goal is to have youth smoking down by 60% in ten years (Smolowe, 1997). Advertising was addressed in this proposed settlement. If Congress passes this settlement, tobacco products will no longer be permitted on billboards, in storefronts or at sporting events. Human and cartoon images would be banned from any advertising that is permitted (Smolowe, 1997). What would the tobacco industry gain from this settlement? The industry would be immune from future state and class-action law suits. This settlement does not restrict individual smokers from suing the industry for medical bills or lost wages, but compensatory damages would be limited to no more than $5 billion per year. The industry would be excused from suits about past wrongdoing (Smolowe, 1997). Congress will be discussing this settlement in their next session, which begins in January of 1998 (Grier, 1997). Although the changes in this proposed settlement are limited to the United States, it would definitely have an impact on the rest of the world (Hoeffel, 1997). 8. Implications for occupational therapy There are several ways in which occupational therapy is involved in issues pertaining to tobacco. The most common would be the treatment of those who have tobacco-related illnesses. Occupational therapists commonly treat patients who suffer from cardiac and respiratory diseases related to smoking. Another occupational therapy intervention is smoking cessation. Through lifestyle revision and counseling, OTs can assist patients to stop smoking. Education is at the forefront of winning the battle over tobacco use. Occupational therapists can play important roles to many populations concerning health and tobacco products. Children should be warned of the dangers of tobacco products in an effort to discourage them from ever starting to smoke or to use smokeless tobacco products. Adults should be reminded of these dangers to reinforce their current knowledge or provide some motivation to quit. Education is especially important in developing countries,

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where illiteracy or lack of regulations make the dangers of smoking relatively unknown. Since occupational therapists are concerned with the quality of life, OTs, through membership in a professional organization, such as AOTA, could be involved in supporting certain legislation that could improve the health of many. Many countries do not have laws limiting places where smoking can occur. Knowing the dangers of environmental tobacco smoke, occupational therapists could urge governments to prohibit smoking in enclosed public areas. 9. Conclusion For hundreds of years, tobacco has been a subject of debate. This debate stems from many different areas. Tobacco consumption continues to increase worldwide with large increases in developing countries offsetting decreases in developed countries. There are many negative health consequences of tobacco use. There are both positive and negative economic implications resulting from the tobacco industry. There are political factors that influence the legislation over the tobacco industry. Tobacco regulation, although it differs from country to country, always has a major effect on the tobacco industry. Although the debate is very strong on both sides of the topic, tobacco consumption and its effects are major factors in our socio-economic, political and medical environments. The congressional consideration of tobacco legislation in the coming months will have an impact for generations to come. References Altman DG et al. Tobacco promotion and susceptibility to tobacco use among adolescents aged 12 through 17 years in a nationally representative sample. Am J Public Health 1996;86:1590-1593. Arno PS et al. Tobacco industry strategies to oppose federal regulation. JAmMed Assoc 1996;275:1258-1262. Barry M. The influence of the US tobacco industry on the environment of developing countries. N Engl J Med 1991;324:917-920. Bartecchi CE, MacKenzie TD, Schrier RW. The global tobacco epidemic. Sci Am 1995;272:44-51. Brown LR, Kane H. More countries raising cigarette taxes to

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