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25 Years of Fighting Tobacco

Grace Fernandez

Jonathan Samet, MD, paints a smoky picture of his early career in medicine when smoking was the norm and was even allowed in hospitals. 

“The so-called nursing station was smoke-filled, some specialties made rounds with cigarettes in their hands, and instructors smoked in class,” said Samet. “The world was completely different.”

Samet, founding director of the Institute for Global Tobacco Control, shared these experiences in a Public Health On Call episode, where he and Joanna Cohen, PhD, MHSc, current IGTC director and Bloomberg Professor of Disease Prevention in the Department of Health, Behavior and Society, discussed the past, present, and future in the fight against tobacco. 

When Samet first came to the Bloomberg School in 1994 to be chair of the Department of Epidemiology, Johns Hopkins “didn’t have a focal point for work on tobacco,” he said.

While the U.S. was starting to see some progress and changes in policy in those years, the tobacco industry strategically turned its marketing efforts to other countries that might not have had the ability to implement strong policies against tobacco. 

“Clearly there was a need for working with colleagues in other countries, moving some of the lessons learned in the U.S. and other higher-income countries to places that faced the peril of the rising use of tobacco with the aggressive and well-honed tactics of the industry,” said Samet. 

Samet’s early work with nations like China spearheaded IGTC’s founding. In 25 years since, the Institute has become a global leader in the efforts to end the tobacco epidemic.
Today, tobacco smoking rates, especially among kids, are declining in the U.S., but the fight against tobacco forges on as new products like e-cigarettes enter the tobacco marketplace.

“There's always an ongoing need, unfortunately, in tobacco control … to counter the ever-shifting strategies of this very chameleon-like industry,” said Cohen. 

Under Cohen’s direction, the IGTC is focusing on global surveillance work to influence tobacco control policies.

For example, IGTC has surveyed tobacco marketing at the point of sale (the physical location where people can buy tobacco products). Cigarettes and other tobacco products are not only seen by people who purchase them, but every other customer “sees all the advertising and the beautiful products displayed,” said Cohen. Another study spanning 42 different countries demonstrates how these products explicitly target children by placing tobacco products at eye level for them to see—and are even advertised and promoted in stores near schools and playgrounds.

With these types of studies and surveillance, Cohen hopes to equip policymakers and public health professionals with evidence to help them say, “We have to do something about this,” and enact policies that will change how cigarettes are designed and where they’re placed in stores.

Many countries, including some low- and middle-income countries, have made major strides in reducing smoking rates. Cohen held in her hand a cigarette pack from Australia, one of the first countries to enforce graphic health warning labels on cigarette packs. The label shows an unsettling image of smoking’s effects and is meant to provoke an emotional response. This particular package showed a protruding eye with the words “Smoking causes blindness.”

In this regard, the U.S. has some catching up to do. 

“We’ve been promised since 2009 with the Tobacco Act that there will be picture warnings. We’re still waiting,” said Cohen.

In other countries, efforts to reduce smoking include banning tobacco displays and putting tobacco products under the counter or behind closed shelves, out of customers’ view.

Samet points to Beijing as a trailblazer for enforcing strict non-smoking ordinances. The city is now 100% smoke-free, but smoking remains pervasive in other parts of the country. China’s government makes and sells cigarettes, primarily through its state monopoly, China National Tobacco, and generates substantial revenues from tobacco.

The future of tobacco control looks to be more complex with tobaccoless, nicotine-filled, fun-flavored e-cigarettes targeting kids.

“We've seen a whole epidemic of youth starting to use these products, getting addicted to nicotine, who would not have used nicotine without these,” said Cohen.

Cohen would like to see the FDA regulate these products to be used for good, like helping people quit smoking tobacco. 

Despite shifting trends in products, Cohen remains optimistic and has her eyes on the tobacco endgame.

“I'm really excited about the energy that's being brought to bringing an end to the tobacco epidemic once and for all.”


Grace Fernandez is a communications associate in the Office of External Affairs at the Johns Hopkins Bloomberg School of Public Health and assistant producer of Public Health On Call.