Policy and politics of smoking control in Japan

Hajime Sato*

Department of Public Health and Occupational Medicine, Graduate School of Medicine, The University of Tokyo, Hongo 7-3-1,

Bunkyo-ku, Tokyo 113-0033, Japan

Abstract

The tobacco industry took root well before the hazards of its products were proven scienti®cally. As elsewhere,smoking control policy has not proceeded automatically nor smoothly in Japan. Examination of the past political

process discloses that the failure to enact e�ective smoking control is attributable to several factors, including thepolitical environment, administrative inadequacy and an inactive medical community. Especially remarkable in thisfailure have been: the political leverage of the tobacco industry; a lack of clear leadership by the health ministry; the

successive rejection of law suits in the courts; and the relatively weak health advocacy groups in Japan. The Diethad been e�ectively immobilized by pro-tobacco interests and without support from the government, administrativeagencies have remained inactive. Since the late 1970s, a series of smoking control measures has been introduced by

government agencies, propelled by the social movement. However limited, the introduction of smoking controlmeasures was accomplished with, or at least facilitated by the following: the advocacy of local and internationalgroups and organizations; the continuous visibility of the issue in the media; and changing public attitudes.

Involvement of the Diet and the Ministry of Health and Welfare (MHW) was essential in translating commitmentsinto government action. Nevertheless, the resulting measures were not comprehensively legislated. Moreover, theywere not subject to continuous evaluation. Consequently, they have been mostly ine�ective in decreasing theprevalence of smoking among the populace. Clearly, leadership by the health ministry coupled with political support

are the key to advancing e�ective smoking control. # 1999 Elsevier Science Ltd. All rights reserved.

Keywords: Smoking control; Policy; Politics; Japan

Introduction

The health hazards of smoking tobacco have been

known for decades, yet many countries have faced dif-

®culties in controlling smoking (American Cancer

Society, 1990; Kluger, 1996). Although the Japanese

government has taken some steps in an attempt to

control cigarette smoking, Japan has had, and con-

tinues to have, one of the highest prevalence among

the industrialized countries. Furthermore, lung cancer

has become the most prevalent cancer among males in

the nation. In order to understand the present situ-

ation in Japan it is necessary to examine the policy

and the politics regarding smoking control.

Government policy on health issues, in general, is

rarely a product of technocratic processes and instead

is mostly a product of politics. This paper documents

the historical evolution of smoking control and its con-

sequences since the 1950s. It then reviews past ®ndings

on smoking control policy and politics in other

countries, proceeds to a discussion of the reasons why

the present set of smoking control policies in Japan is

Social Science & Medicine 49 (1999) 581±600

0277-9536/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved.

PII: S0277-9536(99 )00087-8

* Tel.: +81-3-38164751; fax: +81-3-38164751.

E-mail address: hsato@m.u-tokyo.ac.jp (H. Sato)

ine�ective and why this ine�ectiveness exists. Finally,it seeks to elucidate the critical factor in the promotion

of smoking control in Japan and other countries.

Background

History of tobacco in Japan

Tobacco was ®rst brought to Japan by the

Portuguese early in the 16th century. Besides theimportation of tobacco leaves, the seeds of the plantwere put into the ground almost simultaneously. At®rst, tobacco planting in rice ®elds was strictly prohib-

ited by local governors. In spite of this, by the early17th century the cultivation of tobacco had spreadthroughout the country as far as the northern part of

mainland Japan. In 1615 and 1616, the Shogun startedissuing proclamations that penalized those whosmoked or sold tobacco by con®scating, as a ®ne, all

of the o�ender's possessions, including his house.These edicts sought to make the cultivation of tobaccoa crime. Successive Shoguns followed these policies ofprohibition in vain. By 1625, the Prince was also

known to indulge in tobacco and consent was given tocultivate and process the plant, with prohibitions onlyof its being planted in rice ®elds and vegetable gardens

(Brecher, 1972). Eventually even the Shogun wasreportedly smoking in public. In place of prohibition,a tax on tobacco was introduced by local governments.

After the Meiji Restoration in 1868, private compa-nies began to mass produce tobacco products.Subsequently, in 1883, a national tax on tobacco was

introduced. To collect the tax e�ectively, in 1898, theMeiji Government decided to monopolize leaf cultiva-tion, and in 1905, tobacco manufacturing. Thus, themanufacture and sale of tobacco products were placed

in the hands of the state. By the earliest days of thiscentury, sales of cigarettes were on a sharp rise. Thesmoking habit was becoming more prevalent among

males and then, though more gradually, amongfemales. Finally, smoking became widespread amongminors as well, but this popularity attracted the atten-

tion of the mass media and the general public, result-ing in the Juvenile Smoking Prohibition Law, enactedin 1900. On the other hand, e�orts to curb adult smok-ing were not introduced thereafter. Smoking prevalence

among males has been quite high ever since, althoughthere has been a gradual decline in modern times(JPMC, 1964a).

The Diet and the tobacco industry

The passage of the Japan Public Monopoly Law in1948 established the Japan Public MonopolyCorporation (JPMC). Although supervised jurisdic-

tionally by the Ministry of Finance (MOF), the JPMCretained much of the managerial control over the pro-

duction, distribution and sale of tobacco products.Several advisory councils were created during the nextdecade, either for the Minister of Finance (e.g., the

Monopoly Business Advisory Council), or for the pre-sident of the JPMC (e.g., Tobacco Farming AdvisoryCouncil) (JPMC, 1978a; p. 3±13).

Under the public monopoly system, all retailers wererequired to hold an o�cial retail license from theMOF. The unions of tobacco retailers, established by

the Monopoly Bureau of the MOF in 1931, formedthe Tobacco Retailers' Central Union in 1941. It laterbecame the National Association of Tobacco RetailersCooperatives (NATRC) in 1950. Three other major or-

ganizations of retailers were conferred corporate statusby law: the Tobacco Sales Commercial Cooperative;the Association of the Tobacco Sales Commercial

Cooperative; and the National Tobacco Retailers'Cooperative (JPMC, 1978a, p. 458). The abolishmentof this license system was proposed occasionally, and

each time was accompanied by the protest of the mon-opoly system itself. The NATRC objected to such pro-posals out of the fear that increased retail market

competition would be detrimental to their pro®ts.They were well organized and lobbied politicians vigor-ously when their interests were at stake.Except for the Japan Communist Party, most politi-

cal parties have enjoyed support from tobacco farmersand/or the manufacturers. The long-dominant LiberalDemocratic Party (LDP) has had the strongest ties

with tobacco farmers, since the government procure-ment price of tobacco leaves and the public subsidiesto farmers were both highly political issues for many

years. The Tobacco Farmers' Union and its politicalorganization, the National Political Federation ofTobacco Farmers, could mobilize its members to votefor candidates supporting their interests. The Retailers'

Union also supported the LDP as the principal partyfor the raising of o�cial sales margins (JPMC, 1978b).The Special Committee on Tobacco and Salt

Monopoly has remained one of the largest cross-fac-tional committees in the LDP. There has also been across-partisan group of politicians, 'Diet Action on

Tobacco', some of whose members were backed andreelected by the industry and whose numbers havereached more than 50 and sometimes nearer to 100.

The Ministry of Finance

The ties between the MOF and the JPMC were alsoquite strong. In 1948, the Japan MonopolyCorporation Comptroller's Room was established

under the Finance Minister's Secretariat. This Roomcame to supervise the tobacco business in Japan. Therelationship between the MOF and the JPMC, how-

H. Sato / Social Science & Medicine 49 (1999) 581±600582

ever, did not stop at that of the supervisor and thesupervised. From the beginning, many of the top and

middle managers in the JPMC were recruited from for-mer MOF bureaucrats. For example, many JPMC pre-sidents were former Vice Ministers or former Bureau

Chiefs of the MOF. This system was maintained untilthe abolishment of the JPMC in 1985, when supervi-sion of the newly privatized Japan Tobacco

Incorporated (JT) was assigned to the Salt andTobacco Business Division of the National TreasuryBureau in the MOF.

Evolution of smoking control in Japan

1950±1975: subgovernment politics before thenonsmokers' right (NSR) movements

Since the mid-1950s, medical ®ndings on the hazar-dous e�ects of smoking have been on the increase inthe US and in Europe, and the issue of smoking andhealth increasingly has attracted public notice ever

since. Early in this period there were some especiallysigni®cant alarms sounded: the 1954 statement by UKHealth Minister Macland that smoking and lung can-

cer were statistically associated; the 1957 American

Cancer Association report stating that smokers die atyounger ages; and the 1957 US Surgeon General

(USSG) report stating that smoking was decisively as-sociated with lung cancer (Asahi, July 12, 1957).Perhaps most signi®cant of all was the 1964 USSG

report linking smoking to cancer, which was alsopromptly translated and carried by many newspapersand weekly periodicals in Japan.

In 1950, the prevalence of tobacco use in Japan was81.8% among males and 13.4% among females (Fig.1). Although the incidence of lung cancer was still verylow, a local researcher started epidemiological studies

to quantify the impact of smoking in Japan. When themedia brought the issue to the attention of politicians,the Ministry of Health and Welfare (MHW), urged on

by the discussion in the Diet, called for experts andsought to guide the local governors. This Guidancerequested that they raise the awareness of the public

and advance the enlightenment e�ort about thehazards of smoking (in particular, regarding the sounddevelopment of minors). This was, however, not ac-companied by speci®c action against smoking, either

by the central government or by the local govern-ments.The issue became visible again when the World

Health Organization (WHO) recommendation came to

Fig. 1. Smoking prevalence in Japan.

H. Sato / Social Science & Medicine 49 (1999) 581±600 583

Japan in 1970. It urged the governments of its membercountries to mandate warnings, ban advertising and

limit tar and nicotine contents by law. It also rec-ommended that health workers quit smoking and thegovernment increase its e�orts to prevent juvenile

smoking, and it prompted domestic health organiz-ations to conduct anti-smoking campaigns. The rec-ommendations were passed on to the Minister of

Finance, whose ministry had jurisdiction over theJPMC. The MOF o�cials then did not independentlyseek solutions however. Instead they negotiated with

the industry through the Monopoly Business AdvisoryCouncil. The JPMC acted promptly to refute the accu-racy of the ®ndings and to question the relevance ofthe WHO recommendation. It launched many public

relations campaigns designed to prevent the publicfrom renouncing tobacco products and the habit ofsmoking. It also began to emphasize its own voluntary

commitment to public concern by disclosing tar andnicotine content and by setting a voluntary code onadvertising. The following year, the Council concluded

there was no clear association between smoking andhealth and therefore it was advisable only to put tarand nicotine contents on cigarette packages. It argued

that despite some statistical and epidemiological evi-dence, there was no de®nitive pathological conclusion.The issue required more clinical and psychologicalstudy, including a study on psychological bene®ts.

Regarding advertising, it was deemed that there wasno need for o�cial regulation since the JPMC alreadyimplemented its own voluntary code (MOF, 1971).

While the MOF remained silent on the issue, themedia closely watched the ongoing debate in the Diet,urging prompt o�cial action in preventing health

hazards (Asahi, March 6, 1972). When the Diet criti-cized the council report and started discussing strictermeasures to control smoking, the JPMC and itsworkers' unions employed a variety of lobbying activi-

ties, such as voter mobilization, ®nancial contributionsand petitions in support of their interests.Consequently, not many politicians dared to act

against smoking or take a policy sponsor role. Noopinion survey was conducted to sense public supportfor o�cial actions. Finally, a Finance Minister's Order

to the JPMC was made in 1972 to conform to the ®nalrecommendation made by the Advisory Council, withone exception: mandatory warning labels on cigarette

packages stating, ``For health reasons, be wary ofsmoking too much'', in place of tar and nicotine con-tent. Most of the policies were o�cial legitimization ofvoluntary actions already adopted. Particularly, the

order advocated the JPMC be responsible in discoura-ging juvenile smoking and to conduct its advertisingwith less aggression. The MOF did not involve itself

with enforcement. The policy was not accompanied byspeci®c sanctions against noncompliance nor did it

require o�cial evaluations, leaving a great deal of dis-cretion to the industry in the implementation stage.

Thus, in this period, the media played a major rolein introducing the issue and guiding the debates. TheMHWs commitment, however, was limited only to its

Guidance to local governments. While warning labelswere introduced, tar and nicotine were disclosed andthe JPMC was urged to discourage smoking among

minors, no actual funds were allocated for smokingcontrol. Some public transportation, such as subwaysand international ¯ights, introduced regulations on

smoking (Asahi, May 22, 1974). But in reality, most ofthe o�cial measures were dependent on the industry'svoluntary actions. Tax increases and earmarking offunds were not discussed as measures for smoking con-

trol (the taxation level was 60±65% of retail prices)(JPMC, 1978b, p. 127). In the meantime, cigarettemarketing had already changed substantially. In 1957,

JPMC began cigarette advertising in women's maga-zines (JPMC, 1964b, p. 11). In the same year, cigarettevending machines had been introduced. The number of

machines increased rapidly, from 369 in 1960 to178,000 in 1975 (JPMC, 1978b, p. 127).

1976±1987: emergence of the NSR movement and thegradual involvement of the MHW

In 1976, most of Japan's major newspapers carried a

resolution issued by the 29th WHO General Assemblywhich recommended for its member countries the regu-lation of smoking and protection for nonsmoker popu-

lations. The ®rst nonsmokers' rights group, the Groupfor the Protection of Nonsmokers, was formed and acitizens' movement against smoking spread swiftly.

The term ``Ken-en Ken'', signifying nonsmokers' rightto avoid smoke, literally translates as ``the right tohate smoking''. It was widely covered by the mediaand thereby became well known to the public (Nakata

and Watanabe, 1980, p. 203±205; Kawano, 1982). Twoyears later, the National Interagency Council onNonsmoking and Nonsmokers' Rights, the ®rst nation-

wide network of citizen groups, was created by 11 acti-vist groups, supporting either nonsmoking (to informthe public about smoking cessation) or nonsmokers'

rights (advocating protection from the detrimentale�ects of tobacco). The member groups gathered var-ious reports, both local and foreign and reproduced

them for distribution to the public. They requested theJapan National Railway provide nonsmoking cars andlobbied politicians who might be sympathetic to theirarguments. The e�ective use of mass media and large-

scale petition campaigns were planned and managedby the activists.Although no particular political party tried to estab-

lish a close and constant tie with them, these citizengroups could sometimes ®nd political allies. They

H. Sato / Social Science & Medicine 49 (1999) 581±600584

urged the MHW and the Ministry of Education(MOEd) to openly do more against smoking. Along

with the issue of juvenile smoking, the topics in theDiet concerned the regulation of advertising, the regu-lation of vending machines, the issue of female smok-

ing and the regulation of smoking in publictransportation and hospitals. In response, the MHWissued the Direction to restrict smoking in national

hospitals and sanatria. The Ministry also initiated aneducational program against smoking, using itsa�liated organization, the Health Promotion

Foundation (Mainichi, March 4, 1979).In 1980, when the WHO placed the smoking and

health issue as its focal issue for the World HealthDay, the Japan Anti-Tuberculosis Association (JATA)

launched its `Smoking and Health' campaign. Lobbiedby citizen groups, Dietmembers asked about theMHW's activities planned for the Day. Prompted by

the Diet, the MHW issued its notices to ask local gov-ernments to increase their commitment for smoking-re-lated health education (Nakata and Watanabe, 1980,

p. 219). To justify its commitment, it stated that theWorld Health Day was designed to help broaden con-sumer choice by more extensively supplying the infor-

mation on the health e�ects of smoking. Meanwhile,Takeshi Hirayama, an epidemiologist of the NationalCancer Center, published his report on the e�ects ofhusbands' smoking on the health of nonsmoking wives

(Hirayama, 1981). During the ®rst 'No SmokingWeek' in 1984, the Japan Action Against Smoking(JAAS), a national association of 25 nonsmoking and

nonsmokers' rights groups, held many symposia onsmoking control (Nakata and Watanabe, 1980, p.219). Drawing on their survey ®nding that only two

out of 75 of Tokyo's large hospitals prohibited smok-ing, the group argued for the comprehensive ban ofsmoking in medical facilities. The group also publi-cized its ®ndings in the media that the presence of non-

smoking sections was steadily increasing in publictransportation, schools and workplaces (Tokyo, April6, 1984). Urged by the Diet debates, the MOEd

decided to include nonsmoking education as part ofschool curricula.In 1985, when the JPMC was privatized, the

Tobacco Enterprise Law and its ImplementationRegulation were enacted, containing a section on thenonsmoking measures with which the new Corporation

was to comply. Then, sanctions concerning the viola-tion of the relevant laws were added, although themeasures speci®ed in these laws were mostly the sameas had been applied to the JPMC by the Finance

Minister in 1972. Japan's market liberalization in thefollowing year and subsequent changes in tobaccomarketing highlighted the smoking issue again (Chen

et al., 1990). Market liberalization resulted in increasedmarket competition, which in turn led to more aggres-

sive cigarette marketing. Nonsmokers' right groupsbecame concerned about this consequence and

increased their advocacy e�orts.With the increasing visibility of this issue citizen

groups seized the opportunity to try to incorporate the

MHW in their movement, inviting MHW o�cials totheir symposia and other activities. The Sixth WorldConference on Smoking and Health (WCOSH) was

invited to Japan by citizen activists. Again urged bythe Diet debates, the Ministry agreed to support theconference, playing a management and coordination

role. Furthermore, the Ministry set up the SpecialCommittee on Smoking and Health Issues, with a planto draft a White Paper on Smoking and Health. Thefollowing year, hosted by four health organizations,

the Sixth WCOSH was held in Tokyo which wasattended by 702 people from 56 countries. The MHWhelped form the organizing committee for the confer-

ence with representatives from four health institutions,the JATA, the Japan Cancer Society, the Japan HeartFoundation and the Health Promotion and Fitness

Foundation (JATA, 1989). Concurrently, the WhitePaper was published, which reviewed past scienti®c®ndings on smoking and health. The Occupational

Health Section of the Ministry of Labor (MOL) alsoissued a report, `Workplace and Smoking', which con-®rmed the hazards of smoking in the workplace, docu-mented the spread of smoking regulations in private

companies and recommended that further measures betaken in workplaces (MOL, 1988). Many local govern-ments held symposia on smoking and health, some-

times in cooperation with citizen groups.On the other hand, the tobacco industry created sev-

eral organizations in order to boast of its commitment

to scienti®c research and to legitimize its assertion onthe scienti®c uncertainty of smoking hazards. Aftermarket liberalization, the JT and foreign cigarettemanufacturers established the Tobacco Institute of

Japan (TIOJ) in cooperation with Japanese wholesa-lers. The TIOJ set voluntary regulation codes and con-ducted annual campaigns against juvenile smoking. It

was supposed to promote compliance by its memberswith established cigarette marketing codes and regu-lations, which were positioned as devices to improve

the business environment (Shien, 1987). Orchestratedby the TIOJ, its members loudly denounced the antismoking movement as fanatic and anti liberal and as

trying to prevent the general public from joining theanti smoking movement, meanwhile continuously stres-sing their own political importance to elected o�cials.Thus in this period, despite the emerging nonsmo-

kers' rights movement, no legislative e�orts were madein the Diet, which was subject to substantial in¯uenceof the tobacco industry. Facing the monopoly's priva-

tization and market liberalization, members of theindustry increased their pressure on politicians. The

H. Sato / Social Science & Medicine 49 (1999) 581±600 585

MOF remained inactive, and most of its smoking con-trol measures, such as regulation of sales promotion,

vending machine control and warning labels, did notchange. On the other hand, advocacy and lobbyinge�orts of citizen groups sometimes mobilized the

Ministry into action. The MHW became responsiveand cooperative, although far from proactive: Itrestricted smoking in hospitals, sponsored symposia

and published White Papers. Activities of internationalorganizations and networks highlighted the issue andhelped mobilize the Ministry. Smoking regulation in

public places proceeded mainly through the privatesector. In 1977, the Japan National Railway intro-duced nonsmoking cars, which amounted to 26% ofits rolling stock by 1986 (Nakata and Watanabe, 1980,

p. 34; Asahi, April, 3, 1984). Many other railway andsubway companies introduced `No Smoking Times' intheir stations. Airline companies also increased non-

smoking seats by anywhere from 30 to 60% in thisperiod (Mainichi, January, 12, 1988). As for work-places, an increasing number of private companies

adopted a policy to limit smoking in their o�ces(Mainichi, January 12, 1988). In 1987, 29% of 447companies surveyed took some actions to restrict

smoking in workplaces (MHW, 1993, p. 245).On the other hand, marketing of tobacco products

changed substantially. The number of vending ma-chines continued to grow rapidly, with an increase of

more than 100,000 in ®ve years and tripled in 10 years.The sales from these vending machines comprised 26%of total cigarette sales (Nihon Senbai, July 20, 1983).

The numbers of cigarette ads on television and inmagazines also increased dramatically in this period: in1986, tobacco companies spent about 7.76 billion yen

for TV advertising; 2.46 billion yen for newspaperadvertising; and 2.35 billion yen for the ads in journalsand periodicals (Kitsuen To Kenko Mondai KenkyuKai, 1979).

1988±1996: increasing bureaucratic leadership incooperation with citizen groups

Activities of various domestic and international or-ganizations occasionally became more visible to the

general public. In the annual `No Smoking Week', citi-zen groups launched new nationwide campaignsagainst smoking. Although they were not accompanied

by the large scale mass movements seen in earlieryears, some politicians remained interested in smokingcontrol. Now the initiative of government agencieswould become more readily discerned and the MHW

commitment to the issue more stable. In 1988, theMHW made posters for the `World No Tobacco Day,'and prohibited smoking during all the meetings in its

building. For the ®rst time, the Diet approved theMHW budget proposal of two million yen for World

No Tobacco Day activities. Thereafter the budget forsmoking education was approved annually, which,

although limited, is used to compile reports on smok-ing and health, to hold meetings of special committeesand for o�cial support of nonsmoking educational ac-

tivities made by local governments.In 1992, when part of the Labor Safety and Hygiene

Law was amended, the MHW o�cials argued that

smoking regulation in workplaces should be put intothe law. In 1991, only 27% of private companies hadplaced some limits on smoking in the workplace, even

while 72% of o�ce workers considered some sort ofsmoking regulation desirable in o�ce buildings (SanwaInstitute, 1991). By request of the MHW, three sec-tions were added to the law requiring employers to

improve safety levels and health in the workplace andthe Minister of Labor issued a Guideline for speci®cmeasures, including smoking control. In response to a

petition from the nonsmokers and in compliance withthis Guideline, the Osaka Labor Standard O�ceordered the Transportation Bureau of the city to limit

smoking in their o�ces (Mainichi, May 26, 1993).Other administrative agencies also began to respond topetitions from citizen groups. In 1989, the MOEd

revised its Education Guidelines for junior and seniorhigh schools, placing more emphasis on nonsmokingeducation. The Imperial Household Agency decided tostop using cigarettes as imperial gifts in consideration

of their possible health hazards. In 1993, the MHWreleased its second White Paper on Smoking andHealth and founded the Group on the Action Plan

Against Smoking. This White Paper contained notonly the scienti®c articles on the smoking and healthrelationship, but also numerous reports on the policies

and strategies to decrease smoking. An association ofcitizen groups and nongovernmental organizations wasalso arranged by the MHW to facilitate their com-munications and joint actions. The Asia±Paci®c

Conference on the Control of Tobacco (APACT) washeld through their cooperation.In the meantime, the MOF decided to ask its

Advisory Council to consider smoking regulationbased on a variety of other aspects besides health.Considering the ine�ectiveness of the worn-out health

warning label, the Council decided to revise the warn-ing, recommended tar and nicotine disclosure andacknowledged the importance of information and edu-

cation as a basis for individual choice. However, itsreport still stated that the health hazards of smokingwere not proven and that the e�ects of passive smok-ing are not clear. It acknowledged the positive psycho-

logical e�ects of smoking and concluded that healthpromotion and smoking abstinence are essentially amatter of individual choice (MOF, 1989). In 1989, the

MOF issued its Ministerial Ordinance on vending ma-chines with a speci®c view toward preventing juvenile

H. Sato / Social Science & Medicine 49 (1999) 581±600586

smoking: standalone vending machines locationsshould be changed and be disabled for nighttime oper-

ation, and signs warning against juvenile smokingshould be fastened to them. The TIOJ revised itsvoluntary advertising code subsequently: It changed

the health warning to (`Be Careful Not To Smoke TooMuch For Your Health' and `Have A Good SmokingEtiquette'), put tar and nicotine contents on packages

and tightened regulation on advertising (TabakoSangyo, July 15, 1989). As before, however, no o�cialor nonindustry organizations were given responsibility

for supervising the industry compliance with thesecodes.Thus, in this period, the Diet still remained immobi-

lized by the political leverage of the industry and did

not act on legislation. Although the MHW startedexercising its authority, a large part of its activities stilldealt with issuing reports and recommendations. The

MOF has not substantially changed its o�cial regu-lation on cigarette marketing, and the taxation level(55±60% of retail prices) remain intact (Tabako

Sangyo, May 20, 1995). Although the hours of broad-cast advertising decreased due to voluntary actions bythe industry, it is still on the air at night. The number

of cigarette vending machines has continued toincrease, 495,000 in 1993, accounting for about 40%of total cigarette sales (Tabako Sangyo, March 15,1990; January 15, 1993). Cigarette sales rose for the

®fth consecutive year (Japan Times, April 25, 1995). In1994, the sales of 332.6 billion cigarettes resulted in thetotal sales of 3.78 trillion yen (Tabako Sangyo, April

20, 1994). On the other hand, many private companiescontinued to introduce smoking regulation. In theworkplace, by 1993, 34% of small- and medium-sized

companies had some kind of smoking regulation intheir o�ces, up about 5% since 1987, while 86% oflarge-scale companies (having more than 5000 employ-ees) did so (from 76% in 1987) (Kyodo Tsushin,

October 21, 1993). Smoking regulation increased alsoin public transportation companies (Yomiuri, January8, 1993). Finally local governments took their own

actions, too. A 1992 survey showed that 17 of 46 localgovernments implemented some kinds of educationalprograms against smoking (MHW, 1995).

Smoking and its consequences in Japan

Knowledge and opinion

Available data shows that public knowledge about

smoking hazards increased over several decades,although no consecutive, well-designed survey has beenconducted to monitor this. The following is a summary

of fragmentary ®ndings from past studies: In 1970,53% of those responding to surveys said they knew

that smoking causes lung cancer (PMO, 1973, p. 351).In 1978, about 65% of people knew that smoking is

associated with lung cancer, while more than 85% didso in 1987. The knowledge about its e�ects on otherdiseases was, however, not necessarily as widespread.

Only 10±28% knew that smoking causes prematurebirths in 1978, while about 80% knew it by 1987. Inthe early 1990s, only about 30±45% of the general

population knew that smoking is associated with cardi-ovascular diseases, respiratory diseases and gastriculcers (MHW, 1993, p. 190).

Public opinion about o�cial policies changed overtime, as well. In 1979, despite the spreading publicknowledge and the ongoing nonsmokers' rights move-ment, 84% of males and 62% of females were not con-

cerned about environmental smoke (Nihon Senbai,February 15, 1979). However, public view of smokingchanged over several years (PMO, 1986, p. 156).

Between 1982±1984, about 70% of people thought thatthe government should do more regarding educationon smoking hazards in order to decrease smoking and

75±90% thought it desirable to limit smoking in placeslike public transportation and hospitals (PMO, 1985,p. 429). In 1985, 58±69% of people occasionally found

second-hand smoke annoying and 40±72% thought itdesirable to put stricter limits on smoking in medicalfacilities and in other public places (PMO, 1988, pp.324, 335).

With regard to the rights of nonsmokers, there wasnot unanimous support in the early 1980s: while 37±46% supported such rights, 43±46% did not (PMO,

1989a, p. 322; PMO, 1990, p. 361). The 1991 surveydisclosed that 41.3% supported these rights, while47.8% did not. Public opinion about o�cial smoking

control therefore remained ambivalent. About 70% ofo�ce workers considered some sort of smoking regu-lation desirable in o�ce buildings (Sanwa Institute,1991). But, only 30% supported legislation to restrict

smoking in public places while the same percentage didnot support it (PMO, 1992, p. 362). While 14±33%thought it desirable to restrict TV advertisements, 43%

thought it unnecessary (Mainichi Shimbun, 1987;PMO, 1989b; PMO, 1990, p. 18). Furthermore, about70% thought that smoking was a matter of an individ-

ual choice.

Smoking prevalence and lung cancer incidence

In 1950, the smoking prevalence was 81.8% amongmales and 13.4% among females. In the face of theRoyal College of Physician's Report on smoking

hazards, it gradually decreased. In 1957, when the USreport was delivered to Japan, smoking prevalencedeclined slightly, to 72.1% among males and 9.8%

among females (Nihon Senbai, April 10, 1957).However, the advertisement targeting women started

H. Sato / Social Science & Medicine 49 (1999) 581±600 587

in this same year and smoking among femalesincreased by 30% (to 12.8%) in one year. After the tarand nicotine disclosure, smokers began switching to

brands with lower tar and nicotine contents (Asahi,September 13, 1967). They gradually chose the ciga-rette products with ®lters, too. But the overall sales oftobacco products rose steadily, leading to smoking

prevalence of 78.5% among males and 15.1% amongfemales (JPMC, 1978b, pp. 255±263). Despite theintroduction of warning labels in 1972, there was no

substantial change between 1970 and 1975.By 1976, at the dawn of nonsmokers' rights move-

ment, smoking prevalence was 75.1% among males

and 15.4% among females. It steadily decreasedbetween 1976 and 1987 (1.34% point decrease per yearamong males and 0.34 among females, on average). In1986, 62.5% of males and 12.6% of females smoked

(Nihon Senbai, February 15, 1983) (Table 1).Smoking among males was on a continuous down-

ward trend thereafter, but more slowly, to 59.8% in

1993, while it increased slightly among females, to13.8%. The average annual change in percentagepoints of smoking prevalence in this period were ÿ0.37among males and +0.26 among females. Tabulated byage groups, smoking prevalence was highest amongpeople in their twenties (68.5% among males and

17.5% among females) (Tabako Sangyo, January 15,1992). Consumers continued to switch their brands tothose with low tar and nicotine, but the numbers ofcigarettes consumed per day increased among both

males and females (Tabako Sangyo, July 15, 1992).There was no series of o�cial surveys on smoking

among minors, either. Available reports, however, con-

stantly disclosed that a substantial part of the adoles-cent population smoked. In 1950, 28.9% of smokersstarted to smoke before the age of 19 (Nihon Senbai,

December 10, 1951). The 1960 study disclosed that25.2% of smokers started smoking under the age than

20 (Nihon Senbai, July 5, 1960). Nationwide, 213,822was arrested for juvenile smoking in 1965 and 340,337

in 1979 (Nihon Senbai, February 15, 1966). Other sur-veys between 1982 and 1985 indicated that upwards of25±37% of smokers started under the age of 20 (PMO,

1982, p. 496; PMO, 1989a, p. 303). In 1989, it wasreported that 39.3% of smokers started smoking underthe age of 20. The 1995 survey disclosed that one out

of three high school students experienced smoking,most of whom obtained cigarettes from vending ma-chines (Tokyo, July 16, 1995). More recent surveys

con®rmed these facts, reporting that 37% of male and15% of female students smoked at the age of 18(Ogawa, 1991; Minowa and Ozaki, 1993). Smoking ex-perience and prevalence increase remarkably at the age

of sixteen, upon entering high school. About halfof them purchased cigarettes from tobacconists(Matsuzaki, 1990).

In contrast to the decrease in smoking prevalence,there has never been observed a decline in lung cancerincidence. In the 1960s, although smoking prevalence

was quite high, the age-adjusted cancer mortality ratefrom lung cancer was still very low (8.5/100,000).Japan ranked 23rd out of the 24 developed countries

where lung cancer statistics were then available. But itsteadily increased, so that in 1981, when cancer becamethe most frequent cause of deaths in Japan, lung can-cer ranked second highest (after stomach cancer)

among males and the third highest (after stomach andcolon) among females (MHW, 1990, p. 9). Lung cancerbecame the second most frequent malignancy both

among males and females in 1990 (Mortality ratesfrom lung cancer were 44.3/100,000 among males and15.4/100,000 among females). Then in 1993, it ®nally

became the most frequent cause of malignancy deathfor adult males in Japan (14,981 deaths from lung can-cer in 1993) (Kyodo Tsushin, February 5, 1994).

Discussion

Prevalence is the most useful indicator for assessinga smoking control program (Lopez et al., 1994). In thepast, several countries have experienced a substantial

decline in smoking prevalence. In the US, overallsmoking prevalence declined from 40.4% in 1965 to29.1% in 1987. The rate of decline between 1965 and

1985 was 0.84 percentage points per year (Fiore et al.,1989; Pierce, 1989). Between 1974 and 1987, the aver-age rates of change in smoking prevalence were ÿ0.91among males and ÿ0.33 among females (Pierce, 1989).

In Canada, these rates were ÿ0.21 and ÿ0.49, respect-ively. In Sweden, over the same period, smoking preva-lence decreased by 0.99% points among males and

0.58% points among females (Pierce, 1989).Japan's smoking control policies had some impact

Table 1

Smoking prevalence and its change in Japan

Periods Smoking prevalencea

Range Average Average

annual change

Male 1958±1975 75.9±83.7 78.6 +0.18

1976±1987 62.5±75.1 69.7 ÿ1.341988±1996 58.8±61.2 60.0 ÿ0.37

Female 1958±1975 10.8±18.0 14.5 +0.12

1976±1987 12.6±16.2 14.6 ÿ0.341988±1996 13.1±15.2 14.1 +0.26

a Percentage of adult smokers (Data based on the smoking

prevalence surveys by the JPMC (1958±1984) and the JT

(1985±1996).

H. Sato / Social Science & Medicine 49 (1999) 581±600588

on public perception and attitude around smoking andits control. Many people came to know the hazards of

smoking and during the 38 years between 1958 and1996, smoking prevalence declined by 0.66% pointsper year among men and 0.13% points among females,

on average. The rates of change between 1976 and1987 were comparable to those in other countries.Having had a signi®cantly higher smoking prevalence

in the past, however, the decline in smoking in Japancannot be considered an unquali®ed success, either inrelative terms or in absolute terms, in comparison to

the other countries cited above. This situation iscaused by the lagging behind of o�cial involvement insmoking control, as well as by the ine�ectiveness ofwhatever policies did exist.

Smoking control policies

Collectively, development and dissemination ofscienti®c knowledge and the wide variety of private

and public sector activities intended to reduce the dis-ease burden of smoking have been labeled `the antismoking campaign' (Warner, 1977, 1989; Pierce et al.,1987; DHHS, 1989, p. 383). When countries were

grouped according to the degree of governmentalrestriction of tobacco promotion, the greater thedegree of restriction, the greater were the average

annual falls in tobacco consumption. This was alsotrue for the rate of decrease in the percentage of adultsand young people who smoke (TSB, 1989, pp. 56±77).

They decrease smoking both by a�ecting price levelsand through other mechanisms, including health edu-cation and the formation of a more general antismok-

ing ethos (Dalla-Vorgia et al., 1990). While o�cialpolicies can take various forms, such as laws, ordi-nances, notices and recommendations, legislation isregarded crucial in smoking control. Even after allow-

ing for price and income e�ects, those countries whichhave adopted legislative controls over smoking havereduced national tobacco consumption more than

those countries where only voluntary controls are inevidence (Cox and Smith, 1984). In Norway, forexample, comprehensive legislation decreased smoking,

along with substantial tax increases since 1980(Bjartveit, 1990).On the contrary, the voluntary agreement is a weak

means of controlling tobacco promotion. Voluntary

measures are complex, di�cult to monitor and are sub-ject to di�erences in interpretation, which can hinderimplementation (Roemer, 1993, p. 15). In the UK, the

voluntary agreements contributed little to the restric-tion of tobacco promotion as called for by those con-cerned with health (O'Connor, 1990). In Australia,

tobacco advertising ¯ourished under the nationalVoluntary Code (Woodward et al., 1990). Econometricstudies show that countries with legislative restrictions

have made substantially more progress in containing

and reducing smoking than those with a voluntary

agreement with the tobacco industry (Cox and Smith,

1984; TSB, 1989, p. 64). Consequently, searching for

e�ective smoking control, Australia, Austria,

Denmark, Germany, Sweden and the UK, a number

of other countries that once relied on voluntary agree-

ments came to adopt legislation as a more e�ective

method of control.

Smoking control measures are classi®ed into three

categories (Walsh and Gordon, 1986): (1) Information

and Education (warning, TN disclosure, education,

advertisement regulation), (2) Economic (tax, price

control, insurance premiums), (3) Direct (place, age

and outlet, product). Many countries have adopted all

these measures and their experience con®rmed that

each of them could have an impact on smoking, inde-

pendently or collectively. In the past thirty years,

Japan has used two categories of policy measures, the

economic one being disregarded. (Table 2).

However, they were neither comprehensive nor legis-

lated with clear standards and goals. Most of them

were based on administrative decisions and loosely

enforced without o�cial supervision or evaluation.

The ine�ectiveness of these policies was evidenced by

several reports.

The ®rst category of policies, Information and

Education, includes informative reporting, health

warnings, advertisement regulation and cessation edu-

cation. First of all, o�cial reporting serves as a basis

for public policy decisions. Since the 1950s, the UK

and the US, for example, issued a series of o�cial

reports on the health hazards of smoking.

International organizations and voluntary health or-

ganizations have also been involved in this e�ort

(DHHS, 1989, p. 494). Moreover, the information is

delivered more directly to the public, warning about

the health risks of smoking. In the US, national volun-

tary health agencies have played a signi®cant role in

educating the public. Their mass-media-based messages

and programs substantially increased the public knowl-

edge of the health hazards of tobacco use since 1964

(Flay, 1987; DHHS, 1989, p. 212±221).

Secondly, health warning labels can have an impact

on consumers when designed to take into account fac-

tors that in¯uence consumer response to them (DHHS,

1987; Challat-Traquet, 1996). An Australian study dis-

closed the need to frame messages as clearly and

simply as possible and to provide clear explanations

for terms that are poorly understood but cannot be

avoided in any sensible discussion of risk to health.

Use of conditional words such as `can' or `may' any-

where in the warning can dramatically reduce the e�ect

of the entire warning (Linthwaite, 1985). Furthermore,

warnings of speci®c disease risks were found to be

H. Sato / Social Science & Medicine 49 (1999) 581±600 589

more believable than advice on risk reducing behaviorsor toxic constituents (Beltramini, 1988).

Thirdly, advertisement associates smoking habitswith pleasure, wealth and other themes appealing tomost people, and its regulation is an important part of

information policy. The evidence that advertisingincreases consumption is strong (TSB, 1989, p. 28±55).A single exposure to an advertisement reinforced exist-ing behavior among smokers, created more favorable

attitudes to smoking among nonsmokers, increasednonsmokers' brand awareness and in¯uenced theirbrand preference (Hoek et al., 1993). It is also dis-

closed that children are more vulnerable to advertisingthan adults (DiFrenza et al., 1991). Perception ofadvertising is higher among young smokers, which

encourages youths to smoke (Muramatsu et al., 1990;Pierce et al., 1991). Econometric studies showed thatadvertising bans reduce tobacco consumption

(Bjartvert, 1977; Robson et al., 1982; Roemer, 1993;Harrison and Chetwynd, 1989; Laugesen, 1992;Department of Health, 1992; Townsend, 1993). Theyespecially reduce taking up the habit by young persons.

However, partial bans on tobacco advertising are lesse�ective in controlling tobacco consumption (Roemer,1993, p. 42). This is because, following a partial ban,

the advertising budget is channeled into those avenueswhich remain legal (TSB, 1989, pp. xii±xxii). The per-centage of youth who smoke has fallen more rapidly in

Norway and Finland since their Tobacco Acts bannedadvertisements entirely (Charlton, 1984; Gritz, 1986;

Hunter et al., 1986; Davis, 1987, p. 730; Ticer, 1988).Existence of advertising can in¯uence the information

provided by the media in another way. Evidence fromboth the US and Australia has demonstrated thatthere is an inverse relationship between the acceptance

of tobacco advertising by magazines and the appear-ance of articles on tobacco (Whelan et al., 1981;Warner, 1985; Weis and Burke, 1986; Minkler et al.,1987).

Finally, as for cessation education, there has been atrend toward combining elements of di�erent cessationmethods into programs that respond to the multifac-

torial nature of smoking (Pechacek, 1979; Schwartz,1987; DHHS, 1988). Impersonal approaches such asmass media campaigns, videotapes, lea¯ets and self-

help kits, although quite e�ective at motivating smo-kers to try to quit, are relatively ine�ective at helpingthem to succeed. In contrast, the more personal

approach of brief advice to quit plus a lea¯et andwarning of follow-up, given during face-to-face contactby general practitioners, had a higher success rate(Russell, 1990).

In Japan, while the MHW occasionally sponsoredsymposia on smoking and health since the 1980s, it didnot fully assume authoritative leadership. The MHW

published its White Paper in the late 80s, but its con-tents were sometimes modi®ed by the MOF's requests.Wording of health warnings have been quite vague,

carrying no speci®c risk information. It avoided suchterms as `government', `risk' and `hazard' and did not

Table 2

O�cial policies for smoking control in Japan

Periods

Policy categories I (1950s±1974) II (1975±1987) III (1988±1996)

(1) Information and

Education

1964 Guidance (MHW); 1980 Notice on the

World Health Day (MHW);

1988 World No Tobacco Day

poster (MHW);

1970 TN disclosure and

advertisement codes

(JPMC);

1984±6 School curricula revision

(MOEd);

1989 School curricula revision

(MOEd);

1972 Warning labels (MOF) 1985 Codi®cation of warning

labels and limits on excess

advertisement (MOF);

1989 Health warning revision

(MOF);

1987 WCOSH, White Paper

(MHW)

1993 Second White Paper

(MHW) APACT

symposium (MHW);

1994 Group for Action Plan

(MHW)

(3) Direct regulation 1970 Campaign against minor

smoking: voluntary sales

restriction (JPMC)

1978±84 Smoking restriction in

medical facilities (MHW)

1989 Ordinance on vending

machines (MOF);

1992 Restriction on workplace

smoking (MOL)

H. Sato / Social Science & Medicine 49 (1999) 581±600590

clearly recommend abstinence. Also, their sizes andcolors are left to the manufacturers. Furthermore,

advertisement regulation is mandated by law, but itonly restricts excessiveness without clear standards. Inreality, the industry's voluntary codes are only working

rules. In 1985, 5% of elementary, 58% of junior high,79% of senior high schools provide smoking preven-tion classes (Ishikawa, 1985). However, the e�ective-

ness of these educational programs was notsigni®cantly acknowledged (MHW, 1993, pp. 220±221). Public funding for quitting programs were never

made available from the government. In addition,smoking prevalence among minors was never o�ciallyelucidated.The second category of policies is based on econ-

omic incentives. Increasing tobacco price decreasesconsumption and falling real price (due to increasingdisposable income for example) increases consumption

(Warner, 1990; Townsend, 1993). Tax increases there-fore have reduced cigarette smoking (Burton, 1986;Wasserman et al., 1991; Peterson et al., 1992;

Wasserman, 1992; Facts on File, July 9, 1992).Cigarette prices a�ect smoking primarily by reducingthe participation rate rather than by decreasing the

number of cigarettes per smoker (Lewit and Coate,1982). Further, it was reported that teenage price elas-ticities of demand for cigarettes are larger than adultelasticities (Lewit et al., 1981; Froggatt, 1988; Lewit,

1989). Increased taxes therefore act as deterrents tothose at the start or early into their smoking careers(Alchin, 1992). In Japan, a tax is levied on cigarettes

(about 55±60% of retail prices), but its level is rela-tively low in comparison with other countries. Theywere never discussed or proposed as measures to

decrease smoking (and its consequences), but only toraise revenues. Also important is reducing the supportfor tobacco production. The indirect e�ect is at cross-purposes with the e�ort to combat tobacco consump-

tion because it sustains tobacco production, farmersbecome dependent on in¯ated prices, holders oftobacco allotments rely on income from a nonproduc-

tive subsidy and this economic dependence creates apolitical constituency that supports tobacco productionand promotion (Roemer, 1993, pp. 72±73). This

measure was not taken in Japan substantially as thepublic monopoly system was in place for a long time.The third category of policies involves direct regu-

lation in relation to the age, the place or the product.Few countries have imposed direct control on productspeci®cations. During the early 1970s, however, low-yield cigarettes were introduced and implicitly pro-

moted as less hazardous than conventional productsand gained increasing market shares in many countries(DHHS, 1981, ch. 5; Davis, 1987). In the UK, sales-

weighted average nicotine yields remained relativelyunchanged while average tar yields fell by 23%

between 1975 and 1987. Also in the US, the sales-weighted average nicotine yield declined from 1974

(DHHS, 1989, pp. 313±317). However, the impli-cations of this change are not clear. Potential bene®tsto established smokers have been o�set by their ten-

dency to compensate for reduced nicotine yields(Waller and Froggatt, 1996).Legislation banning smoking in public places has

been enacted in countries including New Zealand, theUS and many of the European Community countries(Walker, 1990; Pais, 1992). Legislation to restrict

smoking in certain public places could induce ad-ditional institutions and commercial establishments toban smoking voluntarily (Roemer, 1993, p. 104). It hasalso been reported that regulations restricting smoking

in public places have a signi®cant e�ect on both adultand teenage cigarette demand (Wasserman et al.,1991). Workplace smoking bans also reduce overall

cigarette consumption, particularly in heavy smokers(Borland et al., 1990). When the regulation is not legis-lated and/or loosely enforced, however, these e�ects

are limited (Scho®eld et al., 1993).Age restriction on smoking is another form of smok-

ing regulation in this category. In many countries,

however, smoking is starting at increasingly youngerages (DHHS, 1989). In the US, approximately 80±90%of smokers begin smoking before age 21 (CDC, 1991).To prevent smoking among minors, control over the

tobacco sales to them is important, but may be di�-cult. Vendor education alone had a limited e�ect andenforcement is sometimes necessary with support at

the judicial level (CDC, 1990; Feighery et al., 1991).Especially important is the restriction of vending ma-chine operation. Vending machines, which, by design

and intent, do not require supervision and allow easyaccess to minors, are considered as major obstacles tothe enforcement of tobacco access laws (WHO, 1975,1976; Bennett, 1985; American Medical Association,

1987; DiFranza et al., 1987; Stanwick et al., 1987).In Japan, the MOF recommended less harmful pro-

ducts, but there is no law to regulate the product speci-

®cations with clear standards. Smoking is prohibited insome public places, including o�cial buildings, publictransportation and medical facilities (MHW, 1993, pp.

245±246). But its adoption and enforcement are basi-cally left to each institution. While the MOL includedsmoking regulation as a necessary measure to improve

workplace environment, it was not rigorously enforced.Smoking under the age of 20 is prohibited by theJuvenile Smoking Prohibition Law of 1900. But a test±purchase study in Japan revealed that about 90% of

retailers were inclined to sell cigarettes to minors overthe counter (Minowa and Satoni, 1993). Also it wasdisclosed that minors have easy access to vending ma-

chines. Retailers sometimes put warnings on theirvending machines, but only 30% of consumers noticed

H. Sato / Social Science & Medicine 49 (1999) 581±600 591

the warning against juvenile smoking (Nihon Senbai,February 15, 1979).

Smoking control politics

Absence of clear governmental leadership and slug-gish governmental involvement in smoking control inJapan are not only attributable to, but result in, the

lack of comprehensive legislation for smoking control.Review of the experiences in other countries and exam-ining Japan's political conditions in light of them clari-

®ed the factors that have caused the present situation.Depending on the political cultures and the strat-

egies pursued by social interests, key factors leading tosuccessful smoking control legislation may be di�erent.

In France, the antismoking activists have employed aninside strategy: well-placed elite in the public healthestablishment persuaded the minister of health and

other key politicians that tougher regulations andhigher excise taxes would be desirable. With its morefragmented political system, the US antismoking advo-

cates more often pursued an outside strategy, seekingto persuade governments to act by in¯uencing publicopinion ®rst. Here they formed grass-roots organiz-

ations, conducted relatively e�ective lobbying andwaged a guerrilla war with local bans designed to de-legitimize smoking as a social practice. In Canada,advocates successfully combined inside and outside

strategies (Popham, 1981; Kagan and Vogel, 1993).Review of past studies on the political process of

smoking control legislation distilled several common

factors contributing to success: strong coalitions, com-mitment of medical communities, executive branch in-¯uence, sympathetic political will (leadership),

international networks, issue framing and media invol-vement. For the country where policy change wasinduced by public pressure, popular support had to beorganized to apply additional pressure for new legis-

lation or for strengthening existing laws. Advocacy,e�orts to shape opinion in support of public policyand lobbying, more direct attempts to in¯uence legis-

lators, have been shown at times to play major roles.An active executive branch, and particularly an aggres-sive approach by o�cial agencies, place additional pol-

itical pressure on the legislature to act. Nationalpolitical will is considerably strengthened also by thecommitment of international agencies. Attitudes may

have changed as a result of restrictions and experiencewith them, or restrictions may have been implementedbecause of changing attitudes, or both (Bull et al.,1994). Public opinion, nevertheless, has served as an

important catalyst for enacting antismoking legislation(Jacobson et al., 1993). Some of these factors are con-sidered important also in the countries where smoking

control proceeded mainly by inside strategies.In the United States, while industry interests were

su�ciently well represented in key congressional com-mittees to block many initiatives, agency initiative

stimulated early governmental consideration of theproblem (Friedman, 1975, p. 155; Taylor, 1984).Advocacy activities and lobbying were almost nonexis-

tent at the time of the 1964 Surgeon General's Report.Then, the Federal Communication Commission (FCC)was induced to ban cigarette advertising because of liti-

gation ®led by a private citizen (Cohen, 1987;Daynard, 1988; Fritschler, 1989). The FCC's rulingwas upheld by the Supreme Court in 1969 and this

helped contribute to changing public opinion on smok-ing (Warner, 1978; Warner, 1986). Secretary of Health,Education and Welfare Joseph Califano's 1978 initiat-ive to combat smoking and a series of o�cial reports

and media coverage also prompted the country todebate the role tobacco should play in society (Bell,1984; Bell and Levy, 1984). Lobbying and advocacy

e�orts have expanded through the increasing commit-ment of national voluntary health agencies to politicalaction and the formation of coalitions at the local,

state and national levels (ASH, 1978). In a courtaction, John Banzhaf III founded ASH as a legalaction arm for the antismoking community and

launched a series of legal challenges to advance smok-ing control policies. Nonsmokers' rights and environ-mental tobacco smoke emerged as important publicissues, particularly since the 1986 Surgeon General's

report on passive smoking (DHHS, 1986). Groupsconcerned about nonsmokers' exposure to environmen-tal smoke proliferated. Activity of advocacy groups set

the stage for many of the changes in prevention andcessation policies (Iglehart, 1986; Eyre, 1988; DHHS,1989, p. 383).

For local politics, as with national, two key ingredi-ents were required for health advocates to overcomethe tobacco industry: a strong coalition within thelocal community and sympathetic political leadership

within the elected body (Glantz, 1987; Samuels andGlantz, 1991). Also important were the manner inwhich the legislative debate was framed, the relative

strength of leadership provided by medical and healthorganizations, the aggressive lobbying of the healthcommissioner and the active support of the governor,

plus favorable public opinion and a complex inter-action between statewide antismoking legislation andlocal antismoking ordinances (e.g., preemption)

(Jacobson et al., 1993). Lack of these resulted in thefailure of legislation.The smoking control legislation in New Zealand

provides another case. In 1990, the Smoke-free

Environments Act was adopted, prohibiting alltobacco advertising. Several factors led to the successof this legislation (Beaglehole, 1991). First was the

changing public attitude. Under the leadership of theNew Zealand ASH, a Great New Zealand Smoke Free

H. Sato / Social Science & Medicine 49 (1999) 581±600592

Week was a successful media event in 1986 (Malcolm,1989). Then in 1990, at the Seventh World Conference

on Smoking and Health, held in Perth, many overseasexperts presented their scienti®c evidence, which justi-®ed the New Zealand public health campaigns. In cor-

respondence, the Toxic Substance Board (TSB) made acomprehensive analysis about possible policy measures.As a result of these activities, smoking control came

onto the agenda and public opinion supported thelegislation (TSB, 1989). Second was the formation of apotent advocacy group, formed by medical organiz-

ations, health charities and advocacy groups. This alli-ance kept the pressure on politicians while raisingpublic awareness. Consequently, political support wassuccessfully solicited. The Minister of Health was

invited to the 1990 Conference to present a keynoteaddress. A dedicated health department played a criti-cal role, too. It assumed an authoritative role in debat-

ing smoking control. Also noted was the relativelyine�ective tobacco industry. With these favorable fac-tors combined, legislative e�orts bore fruit.

Canadian experience also highlighted these factorsas important. In 1988, the Canadian Parliament passedthe Tobacco Products Control Act banning the adver-

tising and promotion of tobacco products (Steacy,1988; Wilson-Smith, 1996). It also requires prominenthealth warnings. The Nonsmokers' Health Act, thesecond of the two major statutes passed in 1988

banned smoking in nearly all federally-regulated work-places (Shulman, 1991). It has been argued that severalfactors converged in the 1980s for smoking control:

well-organized health advocacy coalitions, favorablepublic opinion and political leadership (Mintz, 1990;Mahood, 1990). First, Canadian health lobbies were

remarkable for its cohesiveness, its broad base of sup-port and its e�ectiveness. Major national health organ-izations had already begun organizing joint advocacycampaigns by the early 1980s and provided creative

leadership for tax increases and for advertising restric-tions (Gray, 1987a; Kyle, 1990; Knaus, 1992). TheCanadian Medical Association organized members to

lobby politicians in their home constituencies(Sternberg, 1988; Cipollone vs. Liggett Group, 1992).Second, these groups successfully guided the debate for

smoking control. Although the tobacco lobby hadmanaged to divert the argument from health concernsto other issues, the antismoking coalition used the

media quite e�ectively, framing the debate in healthterms and providing e�ective counter arguments to theindustry's tactics (Corelli et al., 1987; Mintz, 1990).Consequently, public opinion was favorable for o�cial

action (Gray, 1987b; Bull et al., 1994). Third, the pol-itical initiative was there. The Minister of Health, hisministerial sta� and the Department of National

Health and Welfare were all supportive throughout theprocess. Minister Jake Epp lobbied within the Cabinet

and the government Caucus, resulting in support fromall three parliamentary parties.

In France, the country where legislative success wasaccomplished more by elite leadership, several of thefactors cited above played key roles in the enactment

of Law No. 91±32 in 1991. The law imposed a totalban on all tobacco advertising and sponsorship, aswell as a ban on smoking in all enclosed public places

(Smolowe, 1992). While public mobilization and its ac-tivity were not the keys to its success, the coalition ofthe professionals, the sympathy shown by major poli-

ticians, the commitment of the executive branch andmedia activity were considered important. Since 1987,when the ®rst national report on tobacco was pub-lished, public opinion has been changing rapidly in

France ever since (Hirsch, 1990; Gooding, 1992). TheFrench anti tobacco movement, however, did not sig-ni®cantly include grass±roots organizations that chan-

neled popular antismoking sentiment into pressure forregulatory action. Rather, tobacco regulation wasa�ected more by elite bargaining among bureaucrats

and health o�cials. The chief external pressure groupwas the Smoking or Health Medical Association, aloose organization of doctors and academicians. Its

members began to meet repeatedly with politicians andhigh administrative personnel. Furthermore, thedoctors' group and the health minister enlisted supportof sympathetic media organizations to pressure reluc-

tant cabinet members (Kagan and Vogel, 1993).Popular support was used primarily as an opinionsource to justify their policy sponsorship (Ibrahim,

1990).Looking at the political process of smoking control

in Japan, there was no period during which these fac-

tors converged into successful legislation. Lack ofthese key components resulted in political immobiliz-ation, administrative inaction and laggard o�cialinvolvement in smoking control. (Table 3).

In period 1, the issue was introduced by the media,but the health ministry could not e�ectively assumethe authoritative role in reconsolidating scienti®c evi-

dence. There were no visible coalitions against smok-ing, nor were voluntary health organizationsmobilized. While the public became concerned about

the health hazards of smoking, the industry soon tookthe initiative to soothe these public concerns. Althoughsome of the politicians became motivated, the industry

lobbied elected o�cials and negotiated for its prefer-able alternatives. Consequently, most of the politiciansbecame immobilized by the industry, without anyfurther outside push. The Diet and the health ministry

left the issue to the MOF and the industry, whichresulted in loose o�cial actions.In period 2, when the hazards of secondhand smoke

again attracted the public's attention, the national co-alition of the nonsmokers' right groups emerged.

H. Sato / Social Science & Medicine 49 (1999) 581±600 593

Market liberalization also concerned the activists

about the change in cigarette marketing. The publicbecame knowledgeable about health hazards and moreor less supportive of o�cial involvement in smoking

control. About 60±70% of the citizens felt tobaccosmoke was annoying and 85% acknowledged thehealth hazards of secondhand smoke. In the late1980s, many supported the restrictions to smoking in

public places, such as hospitals and transportation(MHW, 1993, pp. 192±193). On major focal events,such as the WCOSH, citizen groups lobbied politicians

and sometimes won administrative actions. E�cacy ofthe health advocacy groups, however, was limited, asexisting health organizations were not involved in lob-

bying. Meanwhile, the political leverage of the industrybecame more powerful. With limited support from theDiet, the MHW remained reactive and stopped at the

point of publishing White Papers. Thus, the oppositionof the powerful industry disarmed the advocacy groupsability in taking either a successful inside strategy oran outside strategy.

In period 3, health advocacy groups continued theirlobbying and advocacy e�orts, but they no longer ac-companied large scale public mobilization as in the

previous period. While the industry's public relationsand voluntary actions gradually soothed public con-cern, the general public became satis®ed with the exist-

ing regulatory status. The tobacco industry tried toframe the public debate about smoking regulationsaround rights and liberty rather than health and itsargument that smoking is an individual choice was

more or less accepted by the public (Sweda andDaynard, 1996). The Diet became less mobilized, too.Health advocacy groups became loosely connected, but

stayed away from lobbying activities. Medical associ-ations in Japan were not signi®cantly involved in thee�orts for smoking control, either. The MHW incor-

porated smoking control as part of its preventive mis-sion and only gradually committed itself to smoking

control. Without a clear political initiative or sympa-

thy, however, smoking control proceeded as sluggishadministrative actions.

Litigation

The tobacco litigation started in the US and in adecade became widespread throughout many other

countries (Daynard, 1990; Rabin, 1992). Litigation,namely the invocation of judicial action, can be a ¯ex-ible and powerful instrument, with the potential for

helping to accomplish a wide range of smoking controlgoals (Roemer, 1993, p. 137; Howard, 1996). In the®rst place, tobacco litigation provides a forum for the

evaluation of smoking behavior and corporate respon-sibilities (Gostin et al., 1991). Secondly, the judgmentcould induce more substantial policy changes, both

public and private. Many cases were ®led, and some ofthem have recognized nonsmokers' rights to a smoke-free workplace, or have ordered compensation for inju-ries attributable to smoking. Sweden's Insurance Court

of Appeal ordered compensation to cover the funeralexpenses for victims of smoking-related diseases (Land,1986). The Cipollone case in the US (Cipollone vs.

Liggett Group, 1992) acknowledged the liability of atobacco company for the health hazards of smoking(Gostin et al., 1991). Nonsmokers also won passive-

smoking cases, such as in an Australian case in 1992(Facts on File, July 9, 1992). Consequently, public andprivate employers began a rapid reassessment of theirpolicies on smoking in o�ces and other work places in

the US (Lush, 1992; Goldman, 1995).In Japan, the courts have rejected many cases and

have not served as agents in advancing smoking con-

trol. First in 1980 and then 1981, cases were ®led forcourt review. Both raised the question about stateresponsibility in regulating the marketing of tobacco

products, based on the Consumer Protection Law. Thecourt rejected these cases, stating that the Law does

Table 3

Political conditions around smoking control in Japan

Periods

Conditions for successful

legislation

I (1950s±1974) II (1975±1987) III (1988±1996)

Political will/leadership Emerged but contained Present but limited Low

Executive branch leadership Minimal (MHW) or

reactive (MOF)

Reactive (MHW) or

inactive (MOF)

Gradually active (MHW)

or inactive (MOF)

Public support/opinion Unavailable Supportive Ambivalent

Coalition None Present Present

Medical community commitment Reporting Limited advocacy Gradually active

International organizations WHO WHO, WCOSH WHO, APACT

Issue framing Health issue Health and nonsmokers' rights Health and rights

H. Sato / Social Science & Medicine 49 (1999) 581±600594

not regulate the use of natural substances and there-fore has no relevance in these cases (JPMC, 1990, pp.

1156±1158). In 1995, the Nagoya District Court againrejected a case which was ®led by ®ve citizens, to banthe import and manufacture of tobacco products. The

judge concluded that the plainti�s did not have legalstanding, based on the Constitution, and the solutionto this issue should be left either to the Diet or to local

Assemblies (Mainichi, March 20, 1995).As for smoking regulation in public places, a judge

ruled on a case ®led by citizen groups in 1987, which

requested the Japan National Railway to provide non-smoking cars. The court rejected this case also, arguingthat even the number of nonsmoking cars was quitesmall, it did not necessarily mean it constituted the

violation of nonsmokers' human rights (Mainichi,January 12, 1988). The court also rejected the argu-ment that passive smoking infringes upon nonsmokers'

rights in the workplace, when, in 1991, the TokyoDistrict Court rejected a case ®led by a researcher thatsought to limit smoking in the Tokyo Metropolitan

Institute of Health. The court acknowledged that whileit was a social trend to limit smoking in public places,the separation of smokers from nonsmokers was not

yet a social custom and could not be considered anestablished `right' (Tabako Sangyo, May 20, 1991;MHW, 1993, p. 255). Her appeal to the SupremeCourt was also rejected. The Nagoya District Court

had previously rejected the case ®led by two schoolteachers in June 1985, which sought to prohibit smok-ing in teachers' rooms in junior high schools (Yomiuri,

March 23, 1991; MHW, 1993, pp. 253±256).

Lessons from Japanese experience

In many countries, including Japan, tobacco use wassocially acceptable before its health hazards becameknown. In these countries, tobacco was taxed and con-

sidered an important revenue source and such levieswere controlled by the ®nancial ministries. Since the1950's, European and US publication of scienti®c

reports on the health hazards of smoking haveattracted the attention of both the public and the pol-icymakers worldwide. However, smoking control has

not been easily introduced through technocratic de-cision. Many individuals, groups and institutions as-sociated with the tobacco business object to o�cial

involvement in smoking control, and many countriesare in a continuous struggle over the control of smok-ing (Whelan, 1984; Pertschuck, 1986; White, 1988).Literature review shows that several smoking control

measures can be e�ective when legislated, but at thesame time a certain set of political conditions isrequired for their enactment. In the case of Japan, the

lack of these conditions, whose combination results inmore prompt and substantial o�cial actions elsewhere,

unfortunately has had as a consequence sluggish andequivocal o�cial involvement in smoking control.

Early establishment of the public monopoly and o�-cial support of it facilitated the political exchangebetween the industry and elected o�cials. The tobacco

industry used this political alliance to prevent o�cialinvolvement in smoking control. Consequently, theDiet has not made e�ective legislative e�orts for smok-

ing control. Although the MHW has had broad juris-dictional competence over health issues, it has not hadspeci®c statutory authority for tobacco regulation. To

establish its jurisdiction and secure resources for smok-ing control, the Ministry required support, or at leastsympathy, from the Diet, which was not easilyexpected. The MHW missed its opportunity for leader-

ship in the 1960s and 1970s, when the issue was not aspoliticized as it became later. It did not e�ectivelyassume an advocacy role based on a then-emerging

consensus in foreign countries. At that time, lung can-cer incidence was still low, the opinions of local scien-tists were not unanimous and institutional resources

were not in abundance. Lack of personal commitment,either by politicians or by high ranking o�cials,further prolonged the immobilization of the agency

and the Diet. Without visible involvement of theMHW, the issue was left to the MOF, by law, whosemission was to foster the industry.Even by the late 1970s and into the 1980s, at the

culmination of the NSR movement, the e�cacy ofhealth advocacy groups was limited both by inside andoutside strategies in confrontation with the pro-

tobacco interests. Lack of o�cial support, both sym-bolic and material, aversion of many health organiz-ations to political activity, and the indi�erence of

medical and other professional organizations to theissue, were all responsible for limiting advocacy groupspolitical e�cacy. Lack of focal points, which couldhave had the kind of impact to orchestrate their activi-

ties, also diminished their e�ectiveness. Nor could theyvery well resort to litigation to induce the desired pol-icy change and administrative action. Meanwhile, the

public relations activities of the industry provided nu-merous counter-arguments to the scienti®c reports thatsupport smoking control, as well as nonsmokers'

rights. Still, now in the 1990s, no strong and stablepolitical initiative is expected.Japan's experience indicates that e�ective leadership,

either by politicians or by administrative agencies, isessential in advancing smoking control. E�ective politi-cal initiative could have opened the policy window forthe health agency. Alternatively, when a majority of

the Dietmembers was under the in¯uence of the indus-try, the mobilization of administrative agencies was thekey to policy change. Its authoritative leadership could

have changed the political environment, enablingfurther involvement in smoking control. Lack of their

H. Sato / Social Science & Medicine 49 (1999) 581±600 595

combination has instead resulted in the laggard o�cialresponse and in the subsequent series of fragmentary

and ine�ective smoking control measures.Grass±root advocacy groups, after the emergence of

secondhand smoke as an issue, has attained limited

e�cacy. Their advocacy and lobbying has sometimesattained visibility in the media and, with the help ofdebates in the Diet, mobilized the MHW to take

action. Activities of international organizations,reports, symposia and conferences, has served as focalpoints to raise public attention to the issue, which has

sometimes evoked political or administrative responses.The action of the MHW, when taken, has mobilizedseveral other agencies. After the publication of theWhite Paper on Smoking and Health, other ministries

have begun responding. The MOL followed theMHW's suit. The MOF and its council set both theadvertisement standards and the codes on the vending

machine establishment. The industry has also beeninduced to respond; the TIOJ has ®nally announcedthat it will voluntarily stop advertising on television

after April 1998. The commitment of medical andhealth communities and the large scale health volun-tary organizations, with their authoritative role and

political in¯uence, could be important in inducing andsubstantiating o�cial e�orts for smoking control,which have not been seen until recently.

Conclusion

The tobacco industry took root well before thehazards of its products were proven scienti®cally. Aselsewhere, smoking control policy did not proceed

automatically and smoothly in Japan. Examination ofthe past political process discloses that the failure toenact e�ective smoking control is attributable to sev-eral factors, including political environment, adminis-

trative inadequacy and an inactive medical community.Especially remarkable has been the political leverage ofthe tobacco industry, a lack of clear leadership of the

health ministry, successive rejection of law suits in thecourts and relatively weak health advocacy groups inJapan. The Diet, meanwhile, remained immobilized by

the pro-tobacco interests and without its support,administrative agencies remained inactive. The estab-lishment and expansion of the tobacco industry sub-

stantially impeded o�cial action to regulate tobaccoproducts. Many developing countries are now estab-lishing their tobacco industries and just entering intothe stage of mass cigarette consumption (Mackay,

1995; Skolnick, 1996). They would do well to be cau-tious about the consequences of their industries.Since the late 1970s, a series of smoking control

measures have been introduced in Japan by govern-ment agencies, under pressure from the social move-

ment. However limited, the introduction of smokingcontrol measures has been accomplished, in whole or

in part, by these means: the advocacy of local and in-ternational groups and organizations; the continuousvisibility of the issue in the media and changing public

attitudes. Debate of the issue in the Diet and the invol-vement of the health ministry were of course the otheressential components. Even when comprehensive and

coordinated actions were not expected, the division ofresponsibility and authority between agencies gave wayfor the MHW's gradual commitment to smoking con-

trol. Resultant policies, however, were not legislatedand were not enforced nor validated with continuousevaluation. Consequently, they have hardly been e�ec-tive in decreasing smoking prevalence. Clear leadership

of the health ministry, coupled with political support,clearly, would be the keys to the enactment of e�ectivesmoking control.

Acknowledgements

The author appreciates the early review of and com-ments on this paper by Professor Michael Reich,

Professor John Montgomery and Professor AllanBrandt of Harvard University. Generous support pro-vided by Professor Shunichi Araki of the University ofTokyo is also acknowledged.

References

Alchin, T., 1992. Tobacco taxation in Australia. Economic

Papers 11, 77±90.

American Cancer Society, 1990. World smoking and health.

American Cancer Society 14, 1±21.

American Medical Association, 1987. Model legislation on the

enforcement of laws to restrict children's access to

tobacco. AMA Proceedings, No. 193. American Medical

Association.

ASH (Action on Smoking and Health), 1978. History of the

War Against Smoking: 1964±1978. Action on Smoking

and Health, Washington, DC.

Beaglehole, R., 1991. Science, advocacy and health policy.

Journal of Public Health Policy 12, 175±183.

Bell, C.S., Levy, S.M., 1984. Public policy and smoking pre-

vention: implications for research. In: Matarazzo, J.D., et

al. (Eds.), Behavioral Health: A Handbook of Health

Enhancement and Disease Prevention. John Wiley and

Sons, New York.

Bell, P., 1984. Anthropological overview of substance abuse.

The Alabama Journal of Medical Sciences 21, 163±165.

Beltramini, R.F., 1988. Perceived believability of warning

label information presented in cigarette advertising.

Journal of Advertising 17, 26±32.

Bennett, W., 1985. Cigarettes: prevention or cure? Harvard

Medical School Health Letter 10 (5), 3±5.

H. Sato / Social Science & Medicine 49 (1999) 581±600596

Bjartvert, K., 1977. The Norwegian Tobacco Act. Health

Education Journal 36, 3±10.

Bjartveit, K., 1990. Fifteen years of comprehensive legislation:

results and conclusions. In: Durston, B., Jamrozik, K

(Eds.), Tobacco and Health 1990: The Global War. Health

Department of Western Australia, pp. 71±80.

Borland, R., et al., 1990. Environmental change as a method

of smoking control: the case of workplace smoking bans.

In: Durston, B., Jamrozik, K (Eds.), Tobacco and Health

1990: The Global War. Health Department of Western

Australia, pp. 493±496.

Brecher, E.M., 1972. Licit and Illicit Drugs. Little Brown and

Company, Boston.

Bull, S.B., et al., 1994. Restriction on smoking: growth in

population support between 1983 and 1991 in Ontario,

Canada. Journal of Public Health Policy 15, 310±328.

Burton, J., 1986. Norway up in smoke. Advertising Age,

April 14.

CDC (Center for Disease Control and Prevention), 1990.

Cigarette Sales to Minors ± Colorado, 1989. Journal of

American Medical Association 264, 2734±2736.

CDC (Center for Disease Control and Prevention), 1991.

Cigarette smoking among youth ± United States, 1989.

Mortality and Morbidity Weekly Report 40, 712±715.

Challat-Traquet, C., 1996. Evaluating Tobacco Control

Activities: Experiences and Guiding Principles. World

Health Organization, Geneva.

Charlton, A., 1984. Smoking and weight control in teenagers.

Public Health 98, 277±281.

Chen, T., et al., 1990. The opium wars revisited as US forces

tobacco exports in Asia. American Journal of Public

Health 80, 659±661.

Cipollone v. Liggett Group Inc., 112S. Ct. 2608, 120 L. Ed.

2d 407, 60 U.S.L.W. 703 (24 June 1992).

Cohen, M., 1987. Cigarette Product Liability Litigation.

Bernstein/James Capel, New York.

Corelli, R., et al., 1987. Crackdown on smoking. Maclean's

100 (22), 24.

Cox, H., Smith, R., 1984. Political approaches to smoking

control: a comparative analysis. Applied Economics 16,

569±582.

Dalla-Vorgia, P., et al., 1990. An evaluation of the e�ective-

ness of tobacco-control legislative policies in European

Community countries. Scand. J. Soc. Med. 18, 81±89.

Davis, R.M., 1987. Current trends in cigarette advertising and

marketing. New England Journal of Medicine 316, 725±

732.

Daynard, R.A., 1988. Tobacco liability litigation as a cancer

control strategy. Journal of the National Cancer Institute

80, 9±13.

Daynard, R.A., 1990. Worldwide Litigation. In: Durston, B.,

Jamrozik, K (Eds.), Tobacco and Health 1990: The Global

War. Health Department of Western Australia, pp. 189±

191.

Department of Health, 1992. E�ect of tobacco advertising on

tobacco consumption: a discussion document reviewing

the evidence. Economics and Operational Research

Division, Department of Health, London.

DHHS (US Department of Health and Human Services),

1981. The Health Consequences of Smoking The Changing

Cigarette: A Report of the Surgeon General. US

Department of Health and Human Services, Public Health

Service.

DHHS (US Department of Health and Human Services),

1986. The Health Consequences of Involuntary Smoking:

A Report of the Surgeon General. US Department of

Health and Human Services, Public Health Service.

DHHS (US Department of Health and Human Services),

1987. Review of the Research on the E�ects of Health

Warning labels. A Report to the United States Congress.

US Department of Health and Human Services, Public

Health Service.

DHHS (US Department of Health and Human Services),

1988. The Health Consequences of Smoking: Nicotine

Addiction. A Report of the Surgeon General. US

Department of Health and Human Services, Public Health

Service.

DHHS (US Department of Health and Human Services),

1989. Reducing the Health Consequences of Smoking: 25

Years of Progress. A Report of the Surgeon General. US

Department of Health and Human Services, Public Health

Service.

DiFranza, J.R., et al., 1987. Legislative e�orts to protect chil-

dren from tobacco. Journal of American Medical

Association 257, 3387±3389.

DiFrenza, J.R., et al., 1991. RJR Nabisco's cartoon camel

promotes camel cigarettes to children. Journal of

American Medical Association 266, 3149±3153.

Eyre, H.J., 1988. The coalition on smoking or health: an

example of the bene®ts of coalition building to in¯uence

national policy. In: Aoki, M., et al. (Eds.), Smoking and

Health 1987. Excerpta Medica, pp. 33±38.

Feighery, E., et al., 1991. The e�ects of combining education

and enforcement to reduce tobacco sales to minors.

Journal of American Medical Association 266, 3168±3171.

Fiore, M.C., et al., 1989. Trends in cigarette smoking in the

United States. Journal of American Medical Association

261, 49±55.

Flay, B.R., 1987. Mass media and smoking cessation: a criti-

cal review. American Journal of Public Health 77, 153±

160.

Friedman, K.M., 1975. Public Policy and the Smoking Health

Controversy. Lexington Books, London.

Fritschler, A.L., 1989. Smoking and Politics: Policy Making

and the Federal Bureaucracy, 4th ed. Englewood Cli�s,

New Jersey.

Froggatt, P., 1988. Smoking and Health. Fourth Report of

the Independent Scienti®c Committee. UK Department of

Health and Social Security. Her Majesty's Stationery

O�ce, London.

Glantz, S.A., 1987. Achieving a smoke-free society.

Circulation 76, 746±752.

Goldman, L., 1995. Tobacco: the road to litigation. Addiction

90, 1581±1586.

Gooding, J., 1992. An ambivalent war against smoking. The

Atlantic Monthly June: 50±56.

Gostin, L.O., et al., 1991. Tobacco liability and public health

policy. Journal of American Medical Association 266,

3178±3182.

Gray, M., 1987a. A growing campaign to clear the air.

Maclean's 100 (3), 44±51.

H. Sato / Social Science & Medicine 49 (1999) 581±600 597

Gray, M., 1987b. Ottawas message to smokers: butt out.

Maclean's 100 (4), 50±51.

Gritz, E.R., 1986. Gender and the teenage smoker. In: Ray,

B.A., Braude, M.C (Eds.), Women and Drugs: A New Era

for Research, NIDA Research Monograph 65. US

Department of Health and Human Services, Public Health

Service.

Harrison, R., Chetwynd, J., 1989. The impact of advertising

of aggregate demand for cigarettes in New Zealand.

British Journal of Addiction 84, 1251±1260.

Hirayama, T., 1981. Nonsmoking wives of heavy smokers

have a higher risk of lung cancer: a case study from

Japan. British Medical Journal 282, 183±185.

Hirsch, A., 1990. Tobacco smoking in France. In: Durston,

B., Jamrozik, K (Eds.), Tobacco and Health 1990: The

Global War. Health Department of Western Australia, pp.

260±261.

Hoek, J., et al., 1993. Some e�ects of tobacco sponsorship

advertisements on young males. International Journal of

Advertising 12, 25±35.

Howard, G., 1996. Tobacco and the law: the state of the art.

British Medical Bulletin 52, 143±156.

Hunter, S.M., et al., 1986. Longitudinal patterns of cigarette

smoking and smokeless tobacco use in youth: the

Bogalusa Heart Study. American Journal of Public Health

76, 193±195.

Ibrahim, Y.M., 1990. French plan to restrict ads: less wine

and no smoking. New York Times, March 29.

Iglehart, J.K., 1986. The campaign against smoking gains

momentum. New England Journal of Medicine 314, 1059±

1064.

Ishikawa, T., 1985. The status and problems of smoking pre-

vention education at schools. Japanese Journal of School

Health 27, 552±556.

Jacobson, P.D., et al., 1993. The politics of antismoking legis-

lation. Journal of Health Politics, Policy and Law 18, 787±

819.

JATA (Japan Anti-Tuberculosis Association), 1989. 50 Nen

No Ayumi. JATA, Tokyo, pp. 160±161.

JPMC (Japan Public Monopoly Corporation), 1964a. In:

Tabako Senbaishi (History of Tobacco Monopoly),

Volume 1. JPMC, Tokyo.

JPMC (Japan Public Monopoly Corporation), 1964b. In:

Tabako Senbaishi (History of Tobacco Monopoly),

Volume 2. JPMC, Tokyo.

JPMC (Japan Public Monopoly Corporation), 1978a. In:

Tabako Senbaishi (History of Tobacco Monopoly),

Volume 3. JPMC, Tokyo.

JPMC (Japan Public Monopoly Corporation), 1978b. In:

Tabako Senbaishi (History of Tobacco Monopoly),

Volume 5. JPMC, Tokyo.

JPMC (Japan Public Monopoly Corporation), 1990. In:

Tabako Senbaishi (History of Tobacco Monopoly),

Volume 6. JPMC, Tokyo.

Kagan, R.A., Vogel, D., 1993. The Politics of Smoking

Regulation: Canada, France, the United States. In: Rabin,

R.L., Sugarman, S.D (Eds.), Smoking Policy: law politics

and culture. Oxford University Press, New York, pp. 22±

48.

Kawano, S., 1982. Osorubeki Tabako. Bunsen Shobo, Tokyo,

pp. 129±130.

Kitsuen To Kenko Mondai Kenkyu Kai, 1979. Tabako To

Kenkou Newsletter. Aichi Prefecture Cancer Institute,

Aichi.

Kluger, R., 1996. Ashes to Ashes. America's Hundred-Year

Cigarette War, the Public Health and Unabashed Triumph

of Phillip Morris. Alfred and Knopf, New York.

Knaus, H., 1992. Targeting corporations: Canada's anti-

smoking program. Multinational Monitor 13, 24±26.

Kyle, K., 1990. Canada's tobacco legislation: a victory for the

health lobby. Health Promotion 1, 9±12.

Land, T., 1986. Life and breath. The New Leader 69, 3.

Laugesen, M., 1992. Tobacco advertising bans cut smoking.

British Journal of Addiction 87, 965±966.

Lewit, E.M., et al., 1981. The e�ects of governmental regu-

lation on teenage smoking. Journal of Law and Economics

24, 545±569.

Lewit, E.M., Coate, T., 1982. The potential for using excise

taxes to reduce smoking. Journal of Health Economics 1,

121±145.

Lewit, E.M., 1989. U.S. tobacco taxes: behavioral e�ects and

policy implications. British Journal of Addiction 84, 1217±

1235.

Linthwaite, P., 1985. Health warnings. Health Education

Journal 44, 218±219.

Lopez, A.D., et al., 1994. A descriptive model of the cigarette

epidemic in developed countries. Tobacco Control 3, 242±

247.

Lush, N., 1992. Australia: implications of court award for

workplace smoking. The Lancet 229, 1406.

Mackay, J., 1995. The tobacco problem: commercial pro®t

versus health, the con¯ict of interests in developing

countries. Journal of American Medical Association 273,

1076±1077.

Mahood, G., 1990. Treating the tobacco epidemic like an epi-

demic: the road to e�ective tobacco control in Canada. In:

Durston, B., Jamrozik, K (Eds.), Tobacco and Health

1990: The Global War. Health Department of Western

Australia, pp. 88±97.

Mainichi Shimbun, Division of Public Opinion Survey, 1987.

The report of the 7th national survey on cancer. Mainichi

Shimbun, Tokyo.

Malcolm, L., 1989. Decentralisation trends in the manage-

ment of New Zealand's Health Services. Health Policy 12,

285±299.

Matsuzaki, M., 1990. Smoking habits of school children in

the northern part of Japan. In: Durston, B., Jamrozik, K

(Eds.), Tobacco and Health 1990: The Global War. Health

Department of Western Australia, pp. 287±289.

MOF (Ministry of Finance), Advisory Council on Tobacco

Business. Division on Smoking and Health Issue, 1971.

Kitsuen To Kenko Mondai Ni Kanren Suru Tabako Jigyo

No Arikata Ni Tsuite. Ministry of Finance, Tokyo.

MOF (Ministry of Finance), Advisory Council on Tobacco

Business. Division on Smoking and Health Issue, 1989.

Kitsuen To Kenko Mondai Ni Kanren Suru Tabako Jigyo

No Arikata Ni Tsuite. Ministry of Finance, Tokyo.

MOL (Ministry of Labor), Occupational Health Section,

1988. Shokuba To Kitsuen. Chuo Roudou Saigai Boushi

Kyoukai, Tokyo.

MHW (Ministry of Health and Welfare), 1990. The Fifth

H. Sato / Social Science & Medicine 49 (1999) 581±600598

Report on Neoplasms in Japan: 1989 survey [Japanese].

Medical Services Bureau, MHW.

MHW (Ministry of Health and Welfare), 1993. Kitsuen To

Kenko (Smoking and Health), 2nd ed. Kenko Tanryoku

Zukuri Jigyo Zaidan, Tokyo.

MHW (Ministry of Health and Welfare), 1995. Heisei 5

Nendo Kitsuen Taisaku Ni Kansuru Chosa. Health

Promotion and Nutrition Section. MHW, Tokyo.

Minkler, M., et al., 1987. Alcohol and cigarette advertising in

MS Magazine. Journal of Public Health Policy 8, 164±179.

Minowa, M., Ozaki, Y., 1993. A national survey of smoking

status among junior and senior high school students.

Japanese Journal of Public Health 40, 39±48.

Minowa, M., Satomi, H., 1993. Illegal sale of tobacco to

minors in Japan. Japanese Journal of Public Health 40,

49±52.

Mintz, M., 1990. No ifs, and, or butts: Canada showed how

to beat the tobacco lobby. The Washington Monthly 22,

30±37.

Muramatsu, J., et al., 1990. The images of elementary school

pupils about cigarette advertising. Japanese Journal of

School Health 32, 230±238.

Nakata, Y., Watanabe, F., 1980. Ken-en No Jidai. Nami

Shobo, Tokyo.

O'Connor, M., 1990. Voluntary agreements between the gov-

ernment and the tobacco industry in the control of

tobacco promotion in the United Kingdom. In: Durston,

B., Jamrozik, K (Eds.), Tobacco and Health 1990: The

Global War. Health Department of Western Australia, pp.

739±740.

Ogawa, H., 1991. The e�ectiveness of smoking prevention

education. Japanese Journal of School Health 33 (suppl),

84±85.

Pais, E., 1992. Snu�ng out cigarettes in Europe. World Press

Review 39, 46.

Pechacek, T.F., 1979. Modi®cation of smoking behavior. In:

Krasnegor, N.A (Ed.), The Behavioral Aspects of

Smoking, NIDA Research Monograph 26. US

Department of Health, Education and Welfare, Public

Health Service.

Pertschuck, M., 1986. Giant Killers. W.W. Norton and

Company, New York.

Peterson, D.E., et al., 1992. The e�ect of state cigarette tax

increase on cigarette sales, 1955 to 1988. American Journal

of Public Health 82, 94±96.

Pierce, J.P., et al., 1987. Targeting the smoker in an anti-

smoking campaign. Preventive Medicine 16, 816±824.

Pierce, J.P., 1989. International comparisons of trends in ciga-

rette smoking prevalence. American Journal of Public

Health 79, 152±157.

Pierce, J.P., et al., 1991. Does tobacco advertising target

young people to start smoking? Journal of American

Medical Association 266, 3154±3158.

Popham, P., 1981. Government and smoking: policy making

and pressure groups. Policy and Politics 9, 331±347.

PMO (The Prime Minister's O�ce), 1973. Yoron Chosa

Nenkan: 1971. Ministry of Finance, Printing Bureau,

Tokyo.

PMO (The Prime Minister's O�ce), 1985. Yoron Chosa

Nenkan: 1984. Ministry of Finance, Printing Bureau,

Tokyo.

PMO (The Prime Minister's O�ce), 1986. Yoron Chosa

Nenkan: 1985. Ministry of Finance, Printing Bureau,

Tokyo.

PMO (The Prime Minister's O�ce), 1987. Yoron Chosa

Nenkan: 1986. Ministry of Finance, Printing Bureau,

Tokyo.

PMO (The Prime Minister's O�ce), 1988. Yoron Chosa

Nenkan: 1987. Ministry of Finance, Printing Bureau,

Tokyo.

PMO (The Prime Minister's O�ce), 1989a. Yoron Chosa

Nenkan: 1988. Ministry of Finance, Printing Bureau,

Tokyo.

PMO (The Prime Minister's O�ce), 1989b. Alcohol and

Tobacco Use among Japanese. The Printing Bureau,

MOF.

PMO (The Prime Minister's O�ce), 1990. Yoron Chosa

Nenkan: 1989. Ministry of Finance, Printing Bureau,

Tokyo.

PMO (The Prime Minister's O�ce), 1992. Yoron Chosa

Nenkan: 1991. Ministry of Finance, Printing Bureau,

Tokyo.

Rabin, R.L., 1992. A sociolegal history of the tobacco litiga-

tion. Stanford Law Review 44, 853±878.

Robson, J.D., et al., 1982. Sponsorship of sport by tobacco

companies. British Medical Journal 284, 395±396.

Roemer, R., 1993. Legislative Action to Combat the World

Tobacco Epidemic, Second Edition. World Health

Organization, Geneva.

Russell, M.A., 1990. How to enhance national rates of smok-

ing cessation. In: Durston, B., Jamrozik, K (Eds.),

Tobacco and Health 1990: The Global War. Health

Department of Western Australia, pp. 49±53.

Samuels, B., Glantz, S.A., 1991. The politics of local tobacco

control. Journal of American Medical Association 266,

2110±2117.

Sanwa Institute, 1991. Survey on the Promotion of Amenable

Workplace Environment. Roudo Mondai Research,

Tokyo.

Scho®eld, M.J., et al., 1993. Smoking control in restaurants:

the e�ectiveness of self-regulation in Australia. American

Journal of Public Health 83, 1284±1288.

Schwartz, J.L., 1987. Review and Evaluation of Smoking

Cessation Methods: United States and Canada, 1978±

1985. National Cancer Institute, Washington, DC.

Shien, T.J.T., 1987. Active, diverse, despite decline. Tobacco

International 189 (17), 5±22.

Shulman, S., 1991. Global smoke out. Technology Review 94,

20±21.

Skolnick, A.A., 1996. Answer sought for `tobacco giant'

China problem. Journal of American Medical Association

275, 1220±1221.

Smolowe, J., 1992. Where there's smoke: following America's

lead, Europeans and Asians join the war on smoking.

Time, November 23, 49.

Stanwick, R.S., et al., 1987. Where Manitoba children obtain

their cigarettes. Canadian Medical Association Journal

137, 405±408.

Steacy, A., 1988. A new nicotine warning. Maclean's 101 (23),

52.

Sternberg, K., 1988. Canada severely limits means for convey-

H. Sato / Social Science & Medicine 49 (1999) 581±600 599

ing tobacco companies' messages to potential users.

Journal of American Medical Association 260, 2480±2481.

Sweda, E.L., Daynard, R.A., 1996. Tobacco industry tactics.

British Medical Bulletin 52, 183±192.

Taylor, P.R., 1984. The Smoke Ring: Tobacco, Money and

Multinational Politics. Pantheon Books, New York.

Ticer, S., 1988. Where there's smoke, there's trouble. Slower

sales have cigarette makers trying promotions, `Smokeless'

brands and price hikes. Business Week, January 18.

Townsend, J., 1993. Policies to halve smoking deaths.

Addiction 88, 43±52.

TSB (Toxic Substances Board), 1989. Health or Tobacco: an

end to tobacco advertising and promotion. Toxic

Substances Board, Wellington, New Zealand.

Walker, A., 1990. Worldwide moves against tobacco pro-

motion. British Medical Journal 301, 458.

Waller, R.E., Froggatt, P., 1996. Product modi®cation.

British Medical Bulletin 52, 193±205.

Walsh, D.C., Gordon, N.P., 1986. Legal approaches to smok-

ing deterrence. Annual Review of Public Health 7, 127±

149.

Warner, K.E., 1977. The e�ects of the anti-smoking campaign

on cigarette consumption. American Journal of Public

Health 67, 645±650.

Warner, K.E., 1978. Possible increases in the underreporting

of cigarette consumption. Journal of the American

Statistical Association 73, 314±318.

Warner, K.E., 1985. Cigarette advertizing and media coverage

of smoking and health. New England Journal of Medicine

312, 384±388.

Warner, K.E., 1986. Protmotion of tobacco products: issues

and policy options. Journal of Health Politics, Policy and

Law 11, 367±392.

Warner, K.E., 1989. E�ects of the antismoking campaign: an

update. American Journal of Public Health 79, 144±151.

Warner, K.E., 1990. Tobacco taxation and economic e�ects

of declining tobacco consumption. In: Durston, B.,

Jamrozik, K (Eds.), Tobacco and Health 1990: The Global

War. Health Department of Western Australia, pp. 81±87.

Wasserman, J., et al., 1991. The e�ects of excise taxes and

regulations on cigarette smoking. Journal of Health

Economics 10, 43±64.

Wasserman, J., 1992. How e�ective are excise tax increases in

reducing cigarette smoking? American Journal of Public

Health 82, 19±20.

Weis, W., Burke, C., 1986. Media content and tobacco adver-

tising: an unhealthy addiction. Journal of Communication

36, 59±69.

Whelan, E.M., 1984. A Smoking Gun: How the Tobacco

Industry Gets Away with Murder. George F. Stickley Co,

Philadelphia.

Whelan, E.M., et al., 1981. Analysis of coverage of tobacco

hazards in women's magazines. Journal of Public Health

Policy 2, 28±35.

White, L.C., 1988. Merchants of Death: The American

Tobacco Industry. Beech Tree Books, New York.

Wilson-Smith, A., 1996. Trying to snu� out smoking.

Maclean's 109, 24±25.

Woodward, S., et al., 1990. Health warnings on tobacco

advertisements: a case study of the failure of voluntary

agreements with the tobacco industry. In: Durston, B.,

Jamrozik, K (Eds.), Tobacco and Health 1990: The Global

War. Health Department of Western Australia, pp. 731±

732.

World Health Organization, 1975. Smoking and its e�ects on

health: report of a WHO Expert Committee. (WHO

Technical Report Series, No. 568), WHO, Geneva.

World Health Organization, 1976. Legislative action to com-

bat smoking around the world: a survey of existing legis-

lation. WHO, Geneva.

H. Sato / Social Science & Medicine 49 (1999) 581±600600