Moving tobacco control beyond “the tipping point”

Next week over 4000 people from about 120 countries will attend the 11th world conference on tobacco or health in Chicago. To mark the occasion, the BMJ, JAMA, and the Bulletin of the World Health Organization are publishing theme issues. At a time of steadily increasing death and disease caused by tobacco and alarming trends in smoking in both developed and developing regions, conference delegates will discuss how to wipe out the “brown plague.”

Malcolm Gladwell, author of the best selling book The Tipping Point,¹ believes he has the answer. He argues that ideas, messages, products, and behaviours spread like viruses. Fashion trends, crime waves, Pokémon, and many other phenomena that characterise everyday life are examples of “epidemics in action.” New ideas, products, or behaviours will cross the threshold into epidemic transmission—that is, move beyond “the tipping point”—if three rules are met. Firstly, people with a “rare set of social gifts,” who are capable of starting epidemics, are involved. Secondly, the “contagion” has the quality of “stickiness,” so that it becomes irresistible and entrenched after exposure occurs. Thirdly, environmental factors—the times and places in which social epidemics occur—are favourable.

Gladwell fits teenage smoking into his model, as evidenced by “tipping people” (such as parents and peers) who initiate teens into smoking and a sticky drug (nicotine). He offers two solutions: treating smokers with bupropion, to address the link between smoking and depression; and reducing nicotine in cigarettes to “non-addicting” levels, to prevent progression from experimentation to dependence. Both strategies are aimed at reducing the stickiness of cigarettes.

Bupropion is indeed an effective smoking cessation medication for people with and without a history of depression.² Reducing nicotine in cigarettes to non-addicting levels was first proposed by Henningfield and Benowitz,³ and the concept was then incorporated into a comprehensive strategy developed by the American Medical Association⁴ and endorsed by the British and Australian medical associations.⁵,⁶ Gladwell's proposals are therefore on target, but they won't move tobacco control beyond the tipping point unless a few essential ingredients are added to the mix.

Firstly, money is needed, and a lot of it. Because governments typically don't provide enough of it for tobacco control, it must come from those involved in the manufacture, sale, promotion, and use of tobacco. Tobacco taxes are the usual source, and these are what fund the comprehensive tobacco control programme in Massachusetts, evaluated in this issue by Biener et al (p 351).⁷ Litigation can produce substantial funding, such as the $246bn made available through the “master settlement agreement” between 46 state attorneys general and US tobacco companies. Unfortunately, only eight states have allocated enough settlement money to fund a comprehensive tobacco control programme.⁸ Retailers should be licensed for the privilege of selling tobacco, and revenues from licence fees should be used to fund enforcement of the minimum age of purchase. In 1990 the Bush administration recommended that tobacco retailers should be required to pay a $300 annual licence fee.⁹

Secondly, the money should be used to fund comprehensive tobacco control programmes like those in Massachusetts, California, Arizona, and a few other “model” states.¹⁰ The US Centers for Disease Control and Prevention recommend that $6-20 per head be allocated annually to fund comprehensive tobacco control programmes, depending on the size of the population.¹¹ The funding and programmes must be sustained over the long term. Massachusetts has spent $6.50 per person per year on its successful campaign since 1993.⁷ Bupropion, nicotine replacement therapy, and other tobacco dependence treatments will not tip the balance unless funding is provided to develop the infrastructure needed to deliver those treatments.¹²

Thirdly, a strong policy structure needs to be in place to support and complement programmes. In this issue Jha and Chaloupka review the policies that are effective in reducing tobacco use, including tobacco tax increases, bans on advertising, bans on smoking in public places and worksites, and prominent warnings on packages (p 358).¹³ Tobacco control policies can be adopted at local, state, national, regional, and global levels. Regional and global approaches—in particular, European Union directives on smoking¹⁴ and the World Health Organization's framework convention on tobacco control¹⁵—offer the greatest opportunity for widespread progress but also present the most challenging political obstacles. The US, ironically, has been a leader in many areas of tobacco control but has been weak on the framework convention.¹⁶

A final essential ingredient is the recruitment and supporting of more “tipping people.” Leaders such as WHO director general Gro Harlem Brundtland, President Bill Clinton, former US surgeon general C Everett Koop, and tobacco litigator Stanley Rosenblatt (see page 322) have blazed the trails. But more funding must be made available to the activists who work in the trenches. Perhaps at the 12th world conference on tobacco or health delegates will grow in number to 12 000, to match the legions that attended last month's global conference on HIV and AIDS.