In 1964, when the U.S. surgeon general's office published the famed report that officially confirmed the link between smoking and cancer, nearly half of American adults smoked.
To understand just how smoky life was back then, watch any episode of Mad Men, the TV series set on Madison Avenue in the early 1960s. Without a second thought, almost every character lights up regularly, at the office, at home, in restaurants, bars, cars, even at the dinner table in front of the kids.
Happily, those days are over. Over the past 40 years, anti-smoking efforts - education, lawsuits, advertising restrictions, cigarette taxes - have had a huge effect on our behavior. Just one in five adults now smokes.
But for much of the planet, the era of pervasive smoking is not over. In fact, it's just getting fired up. In many developing countries, particularly in Asia, smoking rates are above 50 percent. In some places, rates are rising. Especially worrisome: In many poor countries, rates of female smoking are increasing most rapidly.
These trillions of cigarettes will have enormous health consequences. The World Health Organization this year predicted that by 2030, tobacco-related deaths will rise to 8.3 million per year, up from 5 million now. More than 80 percent of those who die will live in developing countries, WHO says - places where health care systems are already strained beyond capacity. In the 20th century, by contrast, 70 percent of tobacco-related deaths occurred in rich countries.
The key engine behind this trend is corporate greed. In developed countries, tobacco use is dropping. To keep their profits high, multinational tobacco companies such as Philip Morris and British American Tobacco are expanding aggressively into new territory.
"They're looking to offset their losses," says Greg Connolly, a professor at the Harvard School of Public Health and an expert on Big Tobacco's global expansion. "Philip Morris has been trained in the U.S., the country that's the most hostile in the world to cigarette smoking. When they go into Armenia or India, it's easy."
In general, developing countries are a cigarette marketer's dream. They typically have little regulation, even less enforcement and low taxes, as well as customers and health officials who often don't realize tobacco's dangers.
Consider China, where more than 300 million people smoke. You'd think China's doctors would be fighting hard against this tsunami of risk. But a 2007 study found that more than 40 percent of the country's male doctors smoke; almost 40 percent of the smoking physicians say they light up in front of patients. China is one of 74 countries that still allow smoking in hospitals.
Big Tobacco has focused particularly on women. In many developing countries, few women smoke, usually because it's seen as improper. In China, the rate is 3 percent; in India, it's below 2 percent. Jonathan Samet, a professor at the Johns Hopkins Bloomberg School of Public Health, says that historically, national tobacco companies tended not to target women. The multinationals have no such reservations, he says: Throughout the developing world, the companies are introducing new brands and flavors aimed at women.
What to do? Since 1999, WHO has been pushing a global treaty, the Framework Convention on Tobacco Control, that requires countries to adopt a range of anti-tobacco measures. The pact has been ratified by more than 150 countries, and is beginning to show results. Since signing the agreement, for example, Mexico has passed a law that prohibits smoking in all workplaces.
Michael R. Bloomberg and Bill Gates have put up $500 million toward an anti-smoking campaign targeting the 15 countries with the worst tobacco problems, including China, India and Indonesia. It will use a comprehensive strategy focused on raising tobacco taxes; banning tobacco ads and promotion; limiting secondhand smoke; educating people about tobacco's hazards; and helping smokers quit.
This approach can work. After the Thai government adopted strong anti-smoking policies in the 1980s, it cut smoking among men by almost half over the next two decades. In the U.S., 24 states and hundreds of cities - including Baltimore - have banned smoking in restaurants and bars. Two decades ago, such limits would have seemed unlikely if not unimaginable. With planning and some help, the developing world can achieve similar success.
David Kohn, a reporter for The Baltimore Sun, spent last year as a
Nieman/Gates Fellow studying global health. His e-mail is