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All articles written by David Simpson unless otherwise attributed. Ideas and items for News Analysis should be sent to: David.Simpson{at}ctsu.ox.ac.uk

Africa: success against the odds

More than 100 people, mostly from Africa, joined by colleagues from the USA and Europe, gathered near Johannesburg in the first week of February for an important African tobacco control conference. This was the latest in the Africa Tobacco Situation Analysis (ATSA) series of meetings to share experience, learn from each other and refresh their energies for the continuing fight against ‘Big Tobacco’. In addition to presentations from the ATSA country teams, delegates also heard from the most recent Gates-funded projects (the African Tobacco Control Consortium and the WHO knowledge hub and capacity building project). Furthermore, there were several interactive sessions for the African tobacco control participants, to identify key actions needed in research, advocacy and policy making and to make plans for the short- and longer term.

What was learnt from the meeting? First, that some countries still have massive difficulties with tobacco industry interference in tobacco control. Several African countries struggle against the odds in this respect and in Africa, the difficulties often seem larger than those in other parts of the world due to the limited resources to fight such a wealthy and unscrupulous opponent. And while tobacco companies are by any measure the enemies of health, they still manage, through political and financial influence, to portray themselves as the ‘good guys’ who are trying to help.

Second, and on a more positive note, successes continue to pile up and there is constant progress in most countries, even though this sometimes appears slow. However, some progress has been highly visible: Mauritius was the first African country to introduce large pictorial health warnings, which cover 65% of the pack surface.

A highlight of the meeting was the announcement by the health ministry of the host country that it would soon join the ranks of countries with totally smoke-free public places. South Africa took an important lead in 2001 when it implemented a ban on smoking in public places, but enclosed, designated smoking areas were still permitted. However, the director general of health told the meeting that the health minister had now approved the principle of totally smoke-free public places and the necessary regulations were in preparation. They will include outdoor areas such as sports stadia, bus and train stations and other areas where people gather in close proximity to one another. Furthermore, the regulations will specify something absent from many countries' legislation: minimum distances from building doorways and entrances, inside which smoking will also be prohibited.

Another bonus for the host country was the participation at sessions of the conference of representatives of the South African Nursing Council—the body which registers professional nurses—and the Democratic Nursing Organisation of South Africa, the nurses' labour union. Both groups were clearly excited about nurses becoming active in tobacco control in South Africa.

One of the most important areas of discussion was article 5.3 of the WHO's Framework Convention on Tobacco Control (FCTC), covering the protection of tobacco control policy from influence or interference by tobacco interests. Delegates were given detailed information about this article, and many seemed excited about its potential for taking action in their own countries. In South Africa and elsewhere, there are now more officials who are positively motivated, being much better informed, to be vigilant for and take measures against tobacco industry interference in the legislative process. As the FCTC bites harder, and as tobacco interests are harder hit, it is likely that this area will be a battleground of significantly more action.

A report of the ATSA meeting, in French and English, together with tobacco control profiles of individual African countries, can be found on the website of the Africa Tobacco Control Consortium: http://www.africatobaccocontrol.org/.

PETER UCKO

National Council Against Smoking, Johannesburg, South Africa

ucko{at}iafrica.com

Figure1

South Africa: Linah Ledwaba and Tasnim Alli, communications officer and projects coordinator respectively at the National Council Against Smoking, at work during the Johannesburg conference in February.

Brazil: PM loses warnings case

Philip Morris (PM), the world's largest cigarette manufacturer outside China, and arguably the most aggressive in fighting effective tobacco control measures, has lost an important legal case about health warnings. PM had challenged Brazil's imposition of striking new graphic tobacco package warnings about serious disease; and although initially it won a favourable judgement, a higher court has now overturned this after an appeal by the Brazilian health ministry.

In 2009, Brazil launched a new series of 10 pictorial warnings for cigarette packs, the third set it has issued. The new warnings generated several complaints from the tobacco industry, particularly the largest two tobacco companies operating in the country, Souza Cruz, a subsidiary of British American Tobacco (BAT) and Philip Morris (PM). The tobacco industry union SindiTabaco in the state of Rio Grande do Sulalso filed a legal complaint against the new warnings.

PM demanded exemption from displaying seven of the 10 new warnings on cigarette packs, at points of sale and on any other promotional materials, arguing that the images were grotesque. It also complained that they did not correctly depict the risks being described in the warnings' text, and would mislead the public by being scary, offensive and with a clear intention of creating aversion and rejection.

PM obtained an initial favourable decision from the second region federal court, but the federal Attorney General's office, as well as the national sanitary surveillance agency, Anvisa—the regulatory agency in charge of implementing and enforcing the warnings—and the federal public defence office appealed against the decision. In the appeal, these federal institutions emphasised that the judge's decision had violated the federal law of 1996 that restricts use and marketing of tobacco products. The law stipulates that all marketing materials associated with tobacco (as well as other substances) must have warnings about harmful effects, and that it is within the scope of the health ministry to establish the content of such warnings.

In November 2010 the superior tribunal accepted the government's arguments and agreed that PM must maintain all 10 warnings in circulation. The seven images that PM wanted to avoid showing were about miscarriage (a fetus in an ashtray), stroke, gangrene, death, myocardial infarction, toxicity, and lung cancer and emphysema.

The final decision also stated that the initial finding, in favour of PM, had violated Brazil's code of consumers' rights, which requires that all products and services need to have accurate and clear information about risks to health and consumers' safety. Additionally, the court found that it was Anvisa's mandate to establish norms, regulate, and to enforce and conduct surveillance of all products, substances and services that might have an impact on health, including cigarette sales and marketing.

The 2008 global adult tobacco survey found that 87.7 per cent of smokers recalled the existing pictorial warnings and 65 per cent of smokers were considering cessation attempts as a result of the warnings. After the judgement against its attempt to avoid most of the new warnings, PM has one more chance to make a further legal appeal; it remains to be seen whether it takes up such an opportunity, or accepts that after such a decisive loss, it had better just circulate some of the world's most truthfully graphic depictions of what may happen to its customers.

ANNA MONTEIRO

Aliança de Controle do Tabagismo (ACT), Brazil

STELLA AGUINAGA BIALOUS

Tobacco Policy International, USA

stella{at}bialous.com

Figure2

Brazil: two of the seven health warnings that Philip Morris did not want to put on Marlboro cigarette packs.

USA: COMPANIES MAY BE FORCED TO RUN ads admitting lies

In February, a federal judge announced a government proposal to make tobacco companies pay for national advertising in newspapers and magazines, and in attachments to cigarette packages, admitting that they lied to the American public about so-called light cigarettes and the addictiveness of nicotine. Judge Gladys Kessler of the District Court in Washington denied a request by the tobacco companies that the recommendations, proposed by the justice department, be kept secret until they had submitted a response. The proposal, for what the government calls ‘corrective statements’, stem from a civil racketeering judgement in 2006 in which Judge Kessler ruled against the tobacco companies, noting that they had lied for 50 years.

The suggested wording of the statements includes one that would say, “We falsely marketed low tar and light cigarettes as less harmful than regular cigarettes to keep people smoking and sustain our profits. We knew that many smokers switch to low tar and light cigarettes rather than quitting because they believe low tar and lights are less harmful. They are NOT.” Another would say in part, “We told Congress under oath that we believed nicotine is not addictive. We told you that smoking is not an addiction and all it takes to quit is willpower. Here's the truth: Smoking is very addictive. And it's not easy to quit. We manipulated cigarettes to make them more addictive.”

Philip Morris USA, the largest US tobacco company, said that the government's proposals “go beyond factual and scientific information” and indicated that it may appeal to a higher court. The tobacco companies are to suggest their own versions for the judge to consider. One industry executive said the proposal was unprecedented in the US legal system and “would violate basic constitutional and statutory standards.” If the proposal is implemented as the government envisages, it will not only be unprecedented, as the industry has pointed out, but insofar as constitutional and statutory standards are concerned, it could only improve the industry's integrity. It would also constitute a world-leading development to correct decades of dishonest tobacco industry propaganda.

Brazil: Marlboro interactive games promotion

Health advocates in Brazil have been disturbed to find that games machines may have been promoting a cigarette brand to young people. A film clip on the website YouTube alerted health officials to a new gaming machine apparently promoting Marlboro cigarettes on the type of machines that are now commonly taken by young promotion agents into clubs, bars and other locations frequented by young people. In a game called Night Runner, players evidently had to try to catch a moving Marlboro logo on screen to win a variety of prizes, including invitations to closed parties, and apparently also tokens, though no details of these have yet emerged. It seems that the machines may also be able to gather information for sending email messages to players at a later date; if these were to promote cigarettes, they would be against the law, as would any attempt to get children to use the machines.

The gaming machines are supplied by a company called Pixellabs, which specialises in helping its clients to promote their products and services using a wide range of new media. A recent marketing industry news report noted that Philip Morris (PM) was using interactive platforms developed by Pixellabs to publicise Marlboro.

The Aliança de Controle do Tabagismo (ACT Br)—the Brazilian alliance for tobacco control—has filed a complaint with the consumer's rights office of São Paulo, asking it to investigate PM for alleged breach of several sections of Brazil's tobacco control law. Whatever the outcome, it is clear that for all the protestations of the multinational tobacco companies that they have changed, there is clearly a long way to go before they are successfully prevented from undertaking all activities that link tobacco with anything attractive to young people.

Figure3

Brazil: a scene from an interactive game featuring Marlboro cigarettes' distinctive logo.

Nicaragua: bat—eco-warriors?

Tourists visiting the beautiful island of Ometepe, formed from two volcanoes in a large lake in the south of Nicaragua, might be forgiven for at first assuming that this protected nature reserve, famous for its exotic flora and fauna, existed entirely due to the generosity of a transnational tobacco company. Signs and posters in many locations proclaim the sponsorship of British American Tobacco (BAT), whose Central American headquarters are in Guatemala. In a country where routine waste recycling has still to be established, the exception is the island, where bins for collecting and separating recyclable materials are prominent, if unused, with metal signs fixed to them bearing the tobacco leaf logo of BAT together with the logos of the local government, town council and the tourist guide association. Posters showing the wildlife species that can be seen in the reserve, displayed in cafés, hotels and at tourist destinations, all proclaim the patronage of BAT.

The website of the company's Caribbean & Central America arm, BATCCA, cites the Ometepeis land project, together with the Jamaica jazz and blues festival recycling campaign, the St Lucia jazz festival recycling campaign, and support for the Zamorano Pan-American School of Agriculture, as examples of the corporate sense of responsibility it feels for environmental protection, in its “double role as company and member of the community.” BAT's shareholders, as well as stockbrokers, financial analysts and large corporate investors, expect the company to deliver the maximum possible profits and stock value growth from their investments. No doubt they would soon make themselves heard if they doubted that significant long term benefits were to be derived from spending their funds on environmental projects. The company boasts of inviting its staff in the region to “plant the trees needed to mitigate the emissions of the [BAT] offices in their countries.” However, it fails to mention any comparable invitations to staff to help mitigate the disease, disability and premature death caused by selling its products.

Switzerland: Winston music promotion

An aggressive new advertising campaign by Japan Tobacco International (JTI) for its Winston cigarette brand has been provoking considerable concern among health advocates. Ads published in Swiss German language newspapers announced that Winston had teamed up with Sony Music and that every pack of Winston cigarettes would offer a music download worth CHF1.50 (US$1.55). The ads showed the Sony Music and Winston cigarette trademarks side by side. The Sony Music download deal was also the key feature of regular Winston cigarette ads in Swiss French language publications, including 20Minutes, a title with a high teenage readership.

No doubt one factor explaining the appearance earlier this year of ads directly linking Winston and youth-flavour popular music is Switzerland's notorious tobacco-friendly reputation (see Switzerland: bad boy of Europe shows no sign of reform. Tob Control 2011;20:89–90).The youth market for downloaded music and electronic gizmos for playing it constitute the very same young people that tobacco companies are so desperate to continue recruiting to smoking, and to keep smoking once they are hooked. Teaming up with a big name in the youth music industry seems a logical step for a tobacco company chasing the youth market—if it is permitted to do so, as in Switzerland.

Figure4

Switzerland: complementary Winston cigarette and music download advertisements.

Pakistan: smokers handcuffed

Many people will remember how, in the days before widespread smoking bans, a journey on public transport or a meal in a restaurant could be ruined by people smoking in the vicinity. Frustration levels were particularly high when there was supposed to be a smoking ban. In such cases, some may have wished that a really severe enforcement method would suddenly become available. But perhaps none would have envisaged what took place recently in Pakistan: regulation-breaking smokers being led away in handcuffs by police officers.

While a ban on smoking in public places was passed in 2002, enforcement was almost entirely lacking until recently. However, in February, the tobacco control unit of the health ministry addressed the problem by running a series of educational activities for the police service. This was followed by a series of widely reported arrests. Four people smoking in a restaurant in Mardan, in the north west of the country, were handcuffed and each fined Rs100 (US$1.17), with similar reports following from the cities of Peshawar and Lahore. By early March, a total of 102 complaints had been logged of alleged breaches of sections of the law. Police in the capital, Islamabad, also became active in checking smoking in public transport, with 13 smokers being fined a total of Rs14 300 (US$ 167.50) for smoking in buses and at bus stops.

Health advocates point out that a major error of the government was to enact the ban without debate, either in parliament or in the electronic and print media, so public awareness of the law was minimal. The publicity following the sudden enforcement of the law in a few locations may help to rectify this, though whether the situation will again deteriorate into widespread law-breaking and non-enforcement remains to be seen.

India: Marlboro mini-packs

Philip Morris (PM) is in trouble again, over another Marlboro promotion, in yet another country. PM's Indian subsidiary, Godfrey Phillips, is distributing two- and three-cigarette packs as a part of a promotional activity, handed out when people complete a product survey. The two-cigarette pack carries a printed price of Rs7 (16 US cents), which Indian health advocates point out is easily affordable to any schoolchild, but it is thought that these packs are mostly given away free. Most strikingly, the smaller pack strongly resembles a chocolate bar. When the outer wrapping is stripped off, so is the health warning. Health advocates are demanding explanations and action by government agencies to stop the distribution of the packs.

Figure5

India: packs of two and three cigarettes that began appearing earlier this year.

China: film & tv smoking limits

The state organisation that oversees radio, television and cinema has ordered television and film producers to limit the amount of smoking shown on screen, and only show smoking when necessary for artistic purposes or for the development of a character. Also, it will not be permitted to show people under the age of 18 smoking or buying cigarettes, and characters may not be seen to smoke in public buildings or other places where smoking is banned.

Egypt: protestors asked, smoking or non-smoking?

In early February, as protests in Tahrir Square in the centre of the capital, Cairo, by those calling for the resignation of their president and government became established, a small detail relayed by the world's news media offered an unexpected indication of how well organised they were. As if they were already a settled community with no intention of moving out of the square until significant demands had been met, the protestors had divided parts of the square into smoking and non-smoking areas.

Kjell Bjartveit

Figure6

Dr Kjell Bjartveit

Health advocates around the world have paid glowing and fond tributes to Dr Kjell Bjartveit of Norway, one of the first international tobacco control campaigners, who died in Oslo in February, aged 83. Among other important posts, Kjell was for many years chairman of Statens Tobakkskaderåd, the national council on tobacco and health. He and the council were unfailingly helpful to colleagues in other countries with responses to the tobacco industry's selective and often dishonest misrepresentation of Norway's pioneering experience, with Finland, of tobacco advertising bans.

He was a member of the first sustained, international tobacco control programme, run by the International Union Against Cancer (the UICC) and led by Dr Nigel Gray of Australia. During the 1970s and 1980s this programme ran short, intensive tobacco control workshops around the world, many of them in low income countries. He was also active for decades with the International Union Against Tuberculosis and Lung Disease, and its president in 1999 and 2000. In retirement, he continued active research, publishing an important paper in this journal on the health consequences of smoking 1–4 cigarettes per day as recently as 2005.

Kjell received many prestigious national and international awards for his work, including the Karl Evang prize for services to health in Norway (1984) and the American Cancer Society's Luther L Terry distinguished career award in 2000. A long-time member of Norway's Christian Democratic party, Kjell held office in the ministry of social affairs in the 1970s.

Kjell was both a superb colleague and a delightful companion. A steadfast religious faith never curbed his broad-minded outlook, nor his irrepressible sense of humour. Once, in a break during a dry policy meeting, he was spotted literally doubled up in helpless laughter over the wash basins in the men's room, after a colleague had told him a somewhat risqué joke, in English. When they met again the following year, Kjell reported his frustration at being unable to find a satisfactory translation of the punch-line into Norwegian.

Kjell was much in demand to inspire other countries to take action and his well known catchphrase, “It can be done!”, was adopted by colleagues all over the world. And how right he was: it can be done, and it is being done, and the part played by Kjell Bjartveit in the extraordinary achievements of the last few decades cannot be overestimated.

Kjell had a long and happy marriage to Eleonora, another doctor of immense dedication, who also served her country at national level, until her death in 2002.

Kjell Bjartveit. 14 August 1927–22 February 2011.

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