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PAKISTAN: PM'S MOBILE CINEMA

Anyone tempted to believe that Philip Morris (PM) has changed its ways should consider what is happening in Pakistan. Readers of this Journal will have seen many of the world's most outrageous forms of tobacco promotion in Pakistan, carried out by the big firms that slaver over its huge, rapidly growing and youthful market, including British American Tobacco and PM. Now, as the World Health Organization's Framework Convention on Tobacco Control (FCTC) is increasingly implemented, it is all too easy to think that such abuses are a thing of the past. Even in countries that have yet to ratify the FCTC, let alone those such as Pakistan that have done so, it might reasonably be assumed that the big international tobacco companies would not be seen to stoop so low.

In Pakistan, however, the FCTC seems to have made no impact at all on the behaviour of PM's local subsidiary, Lakson. In rural areas, where there is comparatively little for young people to do in their leisure time, Lakson is promoting its Diplomat brand by means of a mobile cinema. Lavishly appointed inside the trailer of a large articulated truck, the cinema enables the Diplomat brand to be advertised far beyond the reach of most urban-based promotions. At villages tucked in the folds of the Karakoram foothills in the north, for example, where television signals are weak or non-existent, the arrival of the truck will be a major event and young people will flock to it as thirsty travellers to an oasis.

Figure 2 Pakistan: a Diplomat cigarette ad depicting the brand's mobile cinema.

HONG KONG, CHINA: SLIDING BACKWARDS

All articles written by David Simpson unless otherwise attributed. Ideas and items for News analysis should be sent to: d.simpson@iath.org

In less than two decades during the 1980s and 1990s, Hong Kong went from being the world's most notorious adventure playground for young tobacco advertisers, with little more than the most basic measures in other areas of tobacco control, to something of a model in the region. Making such a journey, which saw it leapfrog ahead of the United Kingdom—of which in those days it was still a colony—was at times exceedingly difficult. After all, the entire economy was built on free trade, something that 30-storey high cigarette ads seemed to shout loud from the city's soaring tower blocks. By the time it was handed back to China, however, regular advertising had been banned and some of the largest tax rises ever recorded had been imposed, setting in hand a healthy decline in consumption.

But there seems to be something rotten in the special administrative region now. At a recent conference convened by the Council on Smoking and Health (COSH) to mark its first 20 years of existence, satisfaction at past successes was outweighed by unease at current trends. Top of the list and most serious in terms of immediate effects on consumption, there has been no tax rise for over 7 years. There was a 4.3 rise in average monthly cigarette sales in 2007 alone compared with the previous year, according to customs authorities, even before any rise in the smuggling that officials like to talk about, industry-style, as a reason not to raise tax.

So why no rise, then? We know that smuggling is a red herring and it is well accepted how important a weapon tax is in the fight against smoking induced disease, with price rises though taxation being specifically prescribed in the World Health Organization's Framework Convention on Tobacco Control, which Hong Kong, through China, has ratified. Most unusually, Hong Kong does not need the extra revenue that usually encourages finance ministries to help themselves at the same time as helping health. Current economic success is such that some direct taxes are being cut: wine, for example, actually had all tax removed at the last budget. But industry voices seem to be heard loudly in the finance ministry, too.

In another vital area, smoking in public places and in the workplace, things have clearly gone wrong. The current legislation banning smoking in most public venues, which took effect in January 2007, allowed proprietors of bars and certain other hospitality venues not serving those under 18 years old to apply for exemptions, albeit only until July 2009. This has given tobacco interests a breathing space to try to prevent the final stage of implementation, even if breathing difficulties are the price many bar staff may have to pay. Worse, mixed messages have been emerging from government about the next step. Even the health minister, who valiantly fought through the legislation, was forced to concede what other senior figures had been suggesting, against all previous announcements, that the government would have to look at the feasibility of smoking rooms. And in due course, news of government expenditure of HK$2.5 million (US$321 000, £161 000, €200 000) on a feasibility study was duly leaked to the press. As one of the foundations of the government's tobacco control policy is that there is no safe level of environmental tobacco smoke, such a study is clearly a complete waste of taxpayers' money, the sort of thing that Hong Kongers normally take rather seriously. In tobacco promotion, too, there are increasingly loud echoes of the bad old days, with brand stretching ads not only more ubiquitous but specifically provided for in the legislation.

How did all this happen? It is hard to resist the theory, for which there is strong if circumstantial evidence, that senior figures in the government have been nobbled by tobacco interests, at least to the point of one-sided lobbying based on the industry's usual lies and sophistries. Even fair minded officials seem to have taken on board industry arguments without the public health lobby having the chance to put them right. Explanations about inaction offered privately by top officials are rife with industry-speak about people "choosing to smoke" and how education is the answer. In fact, repeated requests for serious funding to undertake sustained public education programmes fail to be met; perhaps the government thinks that the large sums given by Philip Morris to one of its infamous "youth smoking prevention programmes" relieve it of responsibility. A decent tax rise could easily pay for what is required and unlike the soft or even dangerous "adult choice" tendencies of industry programmes, could actually be effective. Furthermore, even in this economy where government expenditure is taken so seriously, key decision makers somehow overlook the fact that even conservative estimates of the economic costs of tobacco are almost double the total of tobacco tax revenue.

Hong Kong provides an unfortunate example of how, if a government does not keep reviewing and tightening even a sound tobacco control policy, it can slide back down from the heights of achievement that it had worked hard to attain. Hong Kong has undoubtedly had major distractions, such as SARS and Asian bird flu, albeit causing a fraction of the deaths caused by tobacco, but something else must have distracted it more permanently from following through with its own policies. If the tobacco industry has indeed won much greater and unpublicised access to top decision makers, it will eventually come out and the very people the government professes to want to please, which in a more accountable system would be called the electorate, will not forget that tobacco interests were placed before their own and their children's health and welfare.

Figure 1 Hong Kong: current legislation allows blatant tobacco promotion by means of brand stretching ads.

SPAIN: PARTIAL AIRPORT BANS UNACCEPTABLE

The Spanish tobacco control law that came into force on 1 January 2006 bans smoking in all enclosed workplaces, although it is only a partial ban in the hospitality sector, leading to some bars and restaurants being totally smoke-free, some with smoking areas and some with no restrictions at all (Tob Control 2006;15:79–80). The law, moreover, permits physically separated smoking rooms in enclosed railway stations and airports, provided they have continuous floor-to-ceiling walls and ventilation systems.

Before the law, smoking was permitted in airports in designated smoking points in non-closed areas and in the airport restaurants and cafeterias. The smoking points were installed in the main halls and corridors of airports and sponsored by the tobacco companies. Second-hand smoke exposure in Spanish airports was among the highest in European airports (Tob Control 2005;14:60–3). The Spanish airport authority, Aena, manages all Spanish civil airports and handled more than 210 million passengers in 2007. Since the ban, almost all its airports (43 out of 47) have totally banned smoking in enclosed areas, except in four airports where smoking is allowed in designated smoking points.

Among them, the main international airport, Madrid-Barajas, with 52 million passengers last year, is also the leader, with 35 smoking points in its five terminal buildings, mostly smoking rooms, although there are smoking areas in some cafeterias. The smoking rooms of 20m2 are crowded and the automatic doors are almost always open, often with some smokers actually outside the room. Moreover, continuous messages over the loudspeakers remind smokers that “to respect everybody wishes smoking rooms are available”. Is this a deliberate, subliminal message for smokers, in line with known tobacco industry pressures for “smoker friendly” policies with regard to smoking areas (Tob Control 2004;13:37)?

Preliminary evaluations of the impact of the Spanish law show that it is contributing to a reduction in exposure to second-hand smoke in almost all workplaces and to the prevention of smoking initiation, by limiting the access of young people to tobacco products and prohibits all types of publicity (Tob Control 2008;17:77–8). However, the law clearly has some omissions (Tob Control 2006;15:147–8) that future amendments will have to rectify, including total smoking bans in airports, train stations and all types of hospitality venues.

Esteve Fernández

Institut Catalè d’Oncologia, Barcelona, Spain

efernandez@ico.scs.es

Iñake Galán

Institute of Public Health, Madrid, Spain

Figure 4 Spain: smoking areas at Madrid airport before and after the partial ban.

USA: CAMEL SNUS PLAYS UP SWEDISH HERITAGE

Although both Camel and Marlboro have launched snus products for test-marketing in the United States, the two brands have taken very different marketing approaches in acknowledging the Swedish origins of these products, as evident from their individual snus brand websites (http://www.camelsnus.com and http://www.marlborosnus.com).

Whilst a page on Marlboro Snus’ site indicates that snus was “invented in Sweden,” it clarifies, however, that Marlboro Snus is “perfected in Marlboro Country”. Furthermore, the brand website uses warm colours (such as red, orange and yellow), landscape imagery and examples of adventure-oriented scenarios as situations where using snus is useful (eg while driving off-road), images and themes that are all consistent with the core identity of the flagship Marlboro brand.

In contrast, the website for Camel Snus actively embraces and promotes the product’s connection to Sweden. The website uses winter-themed images (snow-capped mountains, skiers) and cool colours (such as blue) and includes four different Swedish related features. Two of these features specifically revolve around a sexy, blond character named “Inga”, whose coy and flirtatious introduction to snus portrays it as another great thing to come out of Sweden: “When people think of Sweden they think of deep tissue massage, those delicious meatballs, dancing queens and swimsuit models. But Sweden has something else to tantalize your senses—Snus!”

In Inga’s world, snus is not only a historic and popular Swedish tradition but also an action verb rather than merely a noun. She states, “Up here in Sweden we’ve been doing it for over 200 years. In our society, there are many public spaces where smoking isn’t acceptable. These are the perfect places to make like a Swede and snus. Do you know more people in Sweden snus than smoke? Now you know.”

In addition, the Camel Snus website provides a “guide to visiting” Sweden (with information about Swedish festivals, nightlife, hotels, etc) and an interactive “Swedish translator” feature, where users can click on a variety of phrases to hear how the phrase is pronounced in Swedish. Examples include, “What’s your name? My name is...”, "Do they have snus where you live?" and "Where is the nearest bar?" Overall, Camel’s Swedish-related orientation provides some immediate context to what might otherwise be disregarded by consumers unfamiliar with snus (including existing smokers) as just a new silly sounding tobacco product.

Although it is too early to tell the relative effectiveness of these two different approaches, two additional points are of interest. While the images and themes used to promote Marlboro Snus appear to be consistent with those used for its cigarette line, what is unique about this marketing is the use by Philip Morris of a brand-specific website to promote Marlboro Snus. Indeed, unlike R J Reynolds, which has previously created brand websites for many of its brands, the Marlboro Snus site represents Philip Morris's first use of a brand–product specific website.

In addition, one wonders whether Camel’s Swedish-friendly approach to promoting its snus product is intended to reap the benefits of some of the positive associations that have been made about snus in terms of the “Swedish experience” (eg lowered lung cancer rates) without actually making any such specific benefit claims. Informing consumers of a 200-year history of snus use and its current popularity in Sweden may spark consumer curiosity to pursue the topic further. Internet searches about it will inevitably lead the curious to current discussions surrounding snus, including information about the perceived benefits of snus over other forms of tobacco.

Olivia Wackowski and M Jane Lewis

UMDNJ School of Public Health, New Jersey, USA

wackowol@umdnj.edu

Figure 5 USA: Camel Snus internet website.

USA: PM'S RATS, MONKEYS AND ADOLESCENTS

Who would have thought that after all that has been learned about the intentions of tobacco companies that sponsor medical research, a prestigious university and an independent researcher would now take the brown dollar to carry out research on addiction involving brain scans of adolescents? And even then, that one of the defences offered to critics would be how sincere the nice people at Philip Morris (PM) were when agreeing the initial deal?

That is not all that has shocked US health advocates about new research at the University of California, Los Angeles (UCLA). The initial research grant from PM is $6 million (£3.1 million, €3.8 million) and the lead researcher, Professor Edythe London, hopes for more, though not necessarily tobacco money. Would not UCLA proudly announce such a large grant if the university authorities were not feeling just a tad guilty about it? Not at all, they say; any apparent reticence is about the need to protect researchers from militant animal rights activists and, unfortunately, Professor London's home has already been attacked. But some critics think that the university is using the undoubted problems of this issue to cover up the tobacco blight. Disapproval about the funding cannot come as a surprise, as health advocates have been campaigning for UCLA to stop taking tobacco company profit condensate for years.

As for PM, its spokesman pulled off a passable impression of hurt when responding to questions from a newspaper reporter. Commenting on some health workers' fears that PM might be interested in how to develop more addictive cigarettes, he said, "We would never do that." To come over as totally sincere, it would no doubt help people like him to acknowledge that tobacco industry papers reveal that this was precisely the intention of comparable industry research in the past. From such a starting point, tobacco spokespeople would then need to offer detailed reasoning as to why they were so interested in adolescents' tobacco addiction.

Almost as surprising was to learn that, far from being successfully sidelined as social pariahs from whom research dollars are no longer acceptable, tobacco companies' health research funding actually seems to be booming. In publicity over the London money, it emerged that PM is currently funding no less than 23 projects at seven of the University of California's campuses.

Perhaps most astonishing of all, however, was the admission by UCLA that far from Professor London or a department of the university approaching PM for funding, it was the other way around. Apparently, PM knew the sort of research it wanted to do and then approached Professor London. It asked her to prepare and submit a grant application, which she did.

Even suppose it was as simple as that, how good a use of stockholders' money would that be? In the long term, it could only be justified if the board saw a long term gain to future profitability. What if the board said, okay, previous generations of industry leaders commissioned this sort of research so that they could get people hooked more easily, to sell more cigarettes; but we're different and we really do want to develop products that people can take or leave. If we can do that, we'll be known as the only fair-minded tobacco company and in the light of what is now known, that will put us way ahead of the pack. Possible? If it was, wouldn't PM already be crowing about it?

UK: BAT BUYS ARTS PRESTIGE

Glyndbourne is a small, private opera house set in lush countryside in the south of England. To many opera lovers around the world, it ranks alongside the Metropolitan in New York, Covent Garden in London and La Scala in Milan, all long established institutions in large cities, despite being much smaller and less easily accessible. Originally the preserve of a small, mainly wealthy audience seeing productions in the country mansion of the owners, a much larger, purpose-built auditorium now allows far more people the chance of seeing world class opera in the summer months, still with the added bonus of being able to stroll or eat a picnic dinner in sumptuous gardens almost as famous as the opera house itself. To this highly prized reputation of artistic excellence and unrivalled ambience enjoyed by Glyndebourne, surely any connection with tobacco would nowadays be inappropriate under any circumstances?

To the dismay of many of its fans, Glyndebourne has fallen for the brown pound. While one of the six productions this season is sponsored by a British newspaper group and four by generous donations from individuals and trusts, another one sticks out like a sore thumb in the programme: Bizet's Carmen is being sponsored by British American Tobacco (BAT).

Presumably the fact that BAT does not sell a brand using its own name or acronym keeps the sponsorship inside British law, though Action on Smoking and Health is investigating the matter. However, BAT's interest would never have been primarily the promotion of a brand but its ability to buy some much-needed prestige, together with opportunities to entertain business clients in one of the most refined and classy venues in Europe. The most expensive seats at Glyndebourne this season cost £190 (US$380, €238) but the seats at BAT's disposal will probably be in a box reserved for its exclusive use. In the several long intervals that allow guests to stroll across the lawns, champagne glass in hand, or dine in the restaurants or from their own picnic hampers, there will be ample opportunity for subtle lobbying. An ambassador or two from the developing world, accompanied by their spouses? A visiting head of state? Such visitors are run of the mill for Glyndebourne.

Carmen is set in a cigarette factory, which makes it an obvious choice for none-too-subtle BAT. This setting, together with fights among the women who work in the factory, corrupt soldiers and a murder, shocked its first audiences in 1875. However, it soon came to be regarded, as it still is, as one of the finest operas ever written. Such repute no doubt means that none of the violence of the subject matter rubs off on the sponsor. It is unfortunate that the opera house has allowed BAT to bask in its glory, far from the settings for most of the deaths associated with its products.

On top of the outrage felt among those who appreciate the extraordinary achievements of some of the world's operatic artists—one, a retired chest physician who had bought tickets for a performance before he learned of the tobacco connection—is another, distressing anomaly. Carmen is being directed by one of the world's most famous young directors, David McVicar. In addition to his immense skills and long list of achievements, he is admirably direct in some of his press interviews about one reason that he might be so driven to cram in as much work as possible in his hectic life: he suffers from AIDS. Luckily, his remission appears to be set to continue and long may it last. But for someone who has more reason than most to be aware of life threatening disease, it will surely be difficult to attend the obligatory receptions and glad-hand executives of a company whose immense corporate wealth comes from pushing tobacco in developing countries.

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