MsJAMA: new directions in tobacco control.

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THE WORLD HEALTH ORGANIZATION (WHO) ESTIMATES THAT 4 MILLION people will die of tobacco-related illness in 2001 and that this number will climb to 10 million per year by the 2020s. Despite this overwhelming mortality, a significant gap exists between the scientific consensus on the dangers of tobacco use and the political reality of what governments have been able to achieve in terms of tobacco control. Last year, a US Supreme Court judgment stripped the Food and Drug Administration of its authority to regulate tobacco. The past few months have revealed a more insidious setback: a recent study found that the $206 billion master settlement agreement between 46 states and the tobacco industry, which was designed to fund a nationwide campaign to curb tobacco use, has had little effect on cigarette advertising in magazines and on the exposure of young people to these advertisements. Tobacco control involves both politics and science—and since the scientific evidence supporting tobacco regulation is sound and well documented, this suggests that there has been a breakdown in the political process. The health sector and its allied antitobacco forces have been stymied in their efforts to bring about enactment of effective tobacco control measures. While the consensus opinion of the medical community about tobacco-related mortality reflects the strength of epidemiologic and scientific evidence, this opinion does not prescribe any assured method for effecting political change. Having conclusively established the harm that results from tobacco use, the medical community must now find political direction in its antitobacco initiative if it is to be effective. This issue of MSJAMA explores the future of tobacco control. Asaf Bitton, Caroline Fichtenberg, and Stanton Glantz contend that an aggressive national tobacco control program can reduce US smoking prevalence from 22.7% to 10% in 5 years. Anticipating the criticism that such a program might provoke in a nation with a rich and longstanding libertarian tradition, Brion Fox reviews the barriers to tobacco control legislation and argues that such legislation is both appropriate and legally sustainable. Recognizing the emergence of a global tobacco market that demands global regulation, 2 articles present the nascent WHO-sponsored Framework Convention on Tobacco Control (FCTC), the first-ever international health treaty, currently being negotiated. Matthew Myers and Judith Wilkenfeld discuss how the international nature of tobacco trade necessitates an international treaty. Finally, Douglas Bettcher and Chitra Subramaniam describe the ethical and practical imperatives that have led the World Health Organization to pursue the FCTC. As the societal costs of tobacco use continue to grow, the time has come to evaluate the role of legislation in the reduction of tobaccorelated deaths. Having conclusively established the harm that results from tobacco use, the medical community must now find an equally effective political strategy.