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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

Lebanon: testing time as new ad ban takes effect

Since early March, when a ban on tobacco advertising, promotion and sponsorship took effect, health advocates have had their hands full monitoring what looks all too like tobacco companies and their agents trying to ignore, delay compliance with, or just get round the ban. Under the new regulations, no advertising of any sort is permitted anywhere, including in or outside shops or other points of sale, where cigarette packs alone may be displayed, and then only in places where consumers cannot take them directly themselves.

Even before the ban took effect, cigarette companies appeared to be jostling for advantage. In January, for example, a large glittering camel sculpture in a glass case suddenly appeared in the middle of St Nicolas stairs, a central pedestrian way in the Gemmayze district, a key location for art exhibitions and a burgeoning centre of nightlife in the capital, Beirut. Camel cigarettes had only just been launched on the Lebanese market, and the solid camel's appearance coincided with a widespread billboard advertising campaign.

After the ban, however, things became even more desperate. As the cigarette-adorned fascias of small- to medium-sized shops were replaced, it became apparent that many shopkeepers knew little about the new law. Some, questioned by health workers, confirmed that they received significant payment for renting out the spaces above their shop windows, and left it to the tobacco companies or their contractors to undertake the necessary alterations. However, some of the new fascias appeared to retain unmistakeably familiar elements of the cigarette brand colours and designs that were supposed to have been removed. A shop advertising both Camel and Winston brands before the ban, became a new-style Winston shop after it, using the brand's city skyscape and blue and red colours.

Kent cigarette ads also appeared in anomalies spotted by health advocates. One large advertisement above a Beirut shop, showing a Kent cigarette pack before the ban, was replaced by a design that at first sight appeared to be abstract. A moment's examination, however, showed identifiable elements of the Kent pack, as well as the brand's colours and echoes of previous Kent billboard ads, in the new fascia. Health advocates and their advisors realised that considerable thought must have gone into the new designs, apparently to include brand imagery and subliminal cues for cigarette brand promotion. They sent a collage to the health ministry illustrating how the new fascia design related to previous Kent ads, and urging the ministry to use the new law to ban all such promotions. In addition, lawyers have been consulted, to see whether tobacco company funding of such new advertisements could provide sufficient evidence for a court to order their removal.

Figure1

Lebanon: a sculptured camel in a glass case in an area of Beirut noted for art shows and nightlife.

Figure2

Lebanon: a shop front before (top) and after the advertising ban came into force.

Figure3

Lebanon: a collage showing how a new shop front contains elements of previously legal Kent cigarette brand promotions.

India/Australia: row over oral tobacco cricket ads

In February, an Indian oral tobacco brand received television coverage as the Indian cricket team began a test match series in four Australian cities against the home country's team. Cricket is a highly popular game of the masses, with substantial audiences in both countries for television coverage of top level test matches. Viewers noticed boundary rope advertisements in English and Hindi for Chaini, the brand of a range of oral tobacco, as well as other oral products, some containing tobacco, marketed as mouthwash or breath freshener. Oral tobacco causes even more disease and premature death in India than cigarettes and other smoked tobacco.

As virtually all forms of tobacco promotion are banned in both countries, Indian and Australian health advocates filed complaints to their respective governments. Australian health workers also complained to the country's cricket authority, Cricket Australia, which said it had asked the Indian government for a translation of the ads, to be reassured that they promoted a brand of mouthwash, or at least not a tobacco product. However, health organisations in India said most Indians who saw them would instantly associate the ads with oral tobacco.

Cricket Australia was later persuaded that there appeared to be ‘strong parallels’ between the product advertised during the matches and a brand of oral tobacco, and ordered the removal of the ads. It may be liable, nevertheless, to a fine of A$66 000 (US$69 400). Meanwhile, in India, a health organisation which in the past has filed many similar complaints about tobacco brand stretching, said health advocates expected a long wait for a response from their ‘sleeping’ government.

Figure4

India/Australia: how the ad for Chaini brand, which includes an oral tobacco product, appeared on television.

UK: 50 years on, plain packs goal in sight

For many who work in public health, tobacco control began in 1962. That was the year that the first report was published by an established medical organisation reviewing the fast accumulating evidence that tobacco was a major cause of disease, disability and premature death. The publication of Smoking and Health by the Royal College of Physicians of London was a radical move for such an august and innately conservative body. It was the first such publication about a specific topic of public health in its already long history (the college will celebrate its 500th anniversary in just 6 years' time). In addition, after a thorough review of the scientific evidence, the report contained recommendations for action, mostly by government, a feature that was understandably absent from the first report by the government-based US Surgeon General, published 2 years later, which it directly inspired.

A conference held in the college's headquarters in March naturally looked back at what had been achieved over the first half century of firm knowledge about the tobacco problem, but most speakers focused on what was still required to make tobacco use history. As the UK tops the European Union list of tobacco control action taken to date, much of the focus on future work concerned the single largest policy box still waiting to be ticked: plain packaging.

The British government is engaged in consultations about plain packaging, although the health secretary assured the Royal College of Physicians meeting that his ministry was not consulting with the tobacco industry. New pack designs coming onto the market, such as a Benson and Hedges pack featuring what look like Lego toy building blocks, popular among British children, have only increased health demands for plain packs.

A major campaign has been started to gather support for plain packaging legislation, co-ordinated by Smokefree South West, a health promotion organisation sponsored by the National Health Service in south west England. In addition to planning events and publicity campaigns around the country, the Plain Packs Protect campaign (http://www.plainpacksprotect.co.uk/) has recruited a wide range of health and welfare organisations, politicians and opinion leaders to sign up to its aims, to try to ensure the greatest degree of demand for the government to follow Australia's example. Just as with the policy it anticipates, one sure evaluation of its importance has been the emergence of an equivalent campaign against plain packs, funded by tobacco companies and others with vested interests in maintaining business as usual.

Figure5

UK: a Benson and Hedges cigarette pack featuring a device resembling Lego toy building blocks, recently introduced onto the British market.

European Union: new warning texts

In March, the European Commission, secretariat of the European Union (EU), adopted 14 new health warnings to appear on tobacco packs. Written health warnings on tobacco products sold in the EU have been compulsory since 2003 and current legislation foresees their periodic updating. The new health warnings were chosen from among 24 possible messages, following focus group testing with citizens from all 27 EU member states. The warnings were also discussed and agreed with the 27 member state governments.

It has long been known that while most adult smokers in the EU are probably aware that smoking is harmful for their health, they tend to underestimate or ignore the scale and nature of the risks involved. In addition, evidence of lesser known negative consequences of tobacco use, such as mouth and throat cancers, visual impairments and dental and gum disease, is still accumulating. In recognition of this, and of well established evidence that parental smoking acts as an incentive for children's uptake of smoking, the new warning texts include: ‘Smoking causes mouth and throat cancer’; ‘Smoking increases the risk of blindness’; ‘Smoking damages your teeth and gums’; and ‘Smokers' children are more likely to start smoking’.

Member states have 2 years to introduce the new written health warnings. The EU's Tobacco Products Directive also enables member states to combine text warnings with graphic images and pictorial health warnings are currently in place in Belgium, Romania, the UK, Latvia, France, Malta, Spain, Hungary and Denmark. Other member states have passed or are planning similar legislation.

New Zealand: trade ambassador parties with tobacco

While New Zealand's health ministry has committed the nation to going smoke-free by 2025, the country's ambassador to the USA, former prime minister Mike Moore, recently gave out a very different signal about tobacco. In February, Mr Moore, who is also a former director general of the World Trade Organisation (WTO), co-hosted a glamorous event in Washington DC, the Governors and Ambassadors World Trade Reception, sponsored by tobacco company Phillip Morris International.

The reception was held for ambassadors currently engaged in negotiations of the Trans-Pacific Partnership Agreement (TPPA), which aims to secure multilateral free trade between nine countries: New Zealand, the USA, Australia, Brunei, Chile, Malaysia, Peru, Singapore and Vietnam. Although negotiations are being conducted in secret, leaked documents indicate that the TPPA will provide far-reaching protection for industries and investors. If so, the threat of litigation or trade sanctions would effectively curtail any significant further tobacco control improvements that health advocates could otherwise have worked towards.

For instance, if the New Zealand government were to introduce a policy to incrementally reduce the amount of tobacco available for sale in New Zealand, or to remove additives from tobacco, or to reduce and eventually remove nicotine from cigarettes, tobacco companies could use investor-state dispute clauses to have their case heard in secret international tribunals. If found in breach of the TPPA, governments could be forced to pay compensation and costs, or face trade sanctions.

New Zealand, unlike the USA, is a Party to the WHO Framework Convention on Tobacco Control, which under Article 5.3 obligates governments to protect public health policies from commercial and other vested interests of the tobacco industry. Mr Moore's hosting of the event sponsored by the tobacco industry is clearly in direct conflict with the FCTC. In contrast, the Australian ambassador to the USA, Kim Beazley, reportedly withdrew from the same event in protest at Phillip Morris's involvement.

Public health groups in both New Zealand and the USA have expressed outrage at the reception. In New Zealand, this included calls for the ambassador's dismissal. Hone Harawira, leader of the Mana Party, said, “Moore's attendance at this party is a slap in the face for all those who have worked hard to stop the tobacco companies killing thousands of New Zealanders every year, and an insult to those families who have lost loved ones to the country's most addictive drug.” Tariana Turia, associate minister of health and co-leader of the Māori Party, said New Zealand had a moral and ethical duty to eradicate cigarette smoking. “…Our trade interests should align with our social development goals,” she said; “We have set a goal of having a smoke free Aotearoa [New Zealand] by the year 2025. We need to commit to that goal, and our foreign representatives should be promoting this wonderful vision for New Zealand.”

In addition, a group of 24 doctors and other medical professionals wrote to the prime minister, John Key, expressing disappointment at his support for Mr Moore, and pointing out the short-sightedness and inconsistency with the government's stated aims and its international treaty obligations.

Unfortunately, the social development values held by some of New Zealand's Māori (indigenous) politicians are unlikely to be a threat to Mr Moore's career, nor will the protests prevent the sovereignty of nation states being undermined over cocktails and canapés. The TPPA and New Zealand's entry into a trade agreement that would prevent it from implementing policies to achieve a smoke-free New Zealand by 2025 needs to be seriously questioned while there is still a chance to do so.

MAREWA GLOVER

Nathan Cowie Centre for Tobacco Control Research, University of Auckland, New Zealand

m.glover{at}auckland.ac.nz

Figure6

New Zealand: Tariana Turia, associate health minister, who pointed out the conflict in her country's ambassador to the USA being the co-host of a trade reception in Washington DC sponsored by Philip Morris. [Photo: Crown Copyright 2007]

Bulgaria: public places ban

Bulgaria was once the principal tobacco supplier to the central and eastern European countries aligned politically and economically with the former Soviet Union. Local consumption was high, too, even in the medical and health professions: male doctors in Bulgaria had even higher smoking prevalence than all males in the early 1990s. Foreign visitors to Bulgaria reported some of the smokiest conditions they had ever experienced; and one who set about learning Bulgarian reported that the first complete sentence in her language primer was a statement about where tobacco was grown.

Seen in context, therefore, the recent approval by the Bulgarian parliament of an amendment to the country's health legislation to ban smoking in all enclosed public spaces, including restaurants and bars, and near school premises and playgrounds, is a highly ambitious move. There is a partial ban already, but unsurprisingly in a country that has recently emerged as a popular holiday destination for western European visitors, the hospitality industry has been voicing a litany of complaints.

According to opinion polls, a majority oppose the extension of the ban. Smoking prevalence is still high—for example, 55% of Bulgarians aged 26–40 still smoke. A recent poll found that around eight out of 10 of adults questioned, including seven out of 10 non-smokers, said that a total ban would be unlikely to be properly enforced. However, the country's health minister is reported to be firmly behind the measure, which still has to be agreed by cabinet, and repeatedly reassures the country that it will turn out to be popular, and will not hurt the economy.

Indonesia: personal attack on health advocates

People working in tobacco control all over the world were shocked to hear of a public and personal attack on colleagues in Indonesia in February. A large billboard appeared in prominent locations in several cities in the island of Java, showing pictures of 10 people claimed to be the enemies of tobacco farmers and cigarette workers. Those pictured say the poster was commissioned by a pro-tobacco group, the national coalition of kretek (Indonesian clove-flavoured cigarettes) protection.

The ‘enemies’—in fact, a roll of honour in a country that is increasingly isolated in the region for its failure to take serious action on tobacco at the national level—are all strong and prominent supporters of tobacco control:

  • Hakim Sorimuda Pohan, a former member of parliament;

  • Dr Kartono Muhammad, a former leader of the Indonesian medical association, which plays a prominent part in tobacco control advocacy in Indonesia;

  • Endang Rahayu Sedyaningsih, the minister of health, whose strong support for tobacco control is in marked contrast to that of her predecessor;

  • Abdillah Ahsan, a health economist whose research on tobacco tax, tobacco and poverty, tobacco farming and on the myths and facts about the tobacco industry has underpinned support for increasing tobacco tax, and hence revenue. He has also shown that contrary to industry propaganda, tobacco's contribution to the Indonesian economy is small and decreasing;

  • Tulus Abadi of the Indonesian consumers association;

  • Fauzi Bowo, governor of the Indonesian capital, Jakarta, who instigated regulations to make indoor public places 100% smoke-free in the city;

  • Arist Merdeka Sirait and Seto Mulyadi of the national commission for child protection, which has actively monitored and protested against concerts sponsored by the tobacco industry;

  • Azas Tigor Nainggola of the Jakarta citizens' forum, key supporters of the Jakarta smoke-free law;

  • Todung Mulya Lubis, a lawyer prominent in his support for tobacco control.

Figure7

Indonesia: one of the billboards put up by a pro-tobacco group in Java, depicting prominent tobacco control advocates.

Jamaica: new brand of cigarettes

Jamaica has become the latest market for a cigarette brand called ‘bama's’. Imported from an American company by a local businessman, the brand's name is printed on the pack inside a large letter O, shamelessly exploiting the name of US President Barack Obama. As the first African American President of the USA, Mr Obama is a hero of many Jamaicans, particularly young people. Those working to prevent continuing recruitment to smoking in Jamaica, and to reduce the burden of death and disease that it causes, say they are still awaiting any significant action on tobacco control by their government. Complaints have been sent to the health ministry about the new brand, but are considered unlikely to elicit any useful response.

Figure8

Jamaica: part of a newspaper advertisement for the bama's brand of cigarettes when they were launched on the market in January.

Pakistan: from smoking to praying

Health advocates in Pakistan recently reported a significant success, after a campaign to remove designated smoking areas in airports which, they say, are not permitted under national tobacco control legislation. In response to their campaign, the airport authorities in Karachi, the country's largest city, have now turned a designated smoking area into a special mosque where women at the airport can say their prayers.

LAOS: marlboro lookalike sweet cigarettes

For many years and in every corner of the world, the big international cigarette companies have guarded assiduously their ‘intellectual property’, including the copyright of their brands' designs, distinctive colour schemes and typefaces. If ‘lookalike’ designs are discovered on products or in publications that carry negative messages about smoking, the manufacturers typically take immediate legal action, threatening severe financial damages, usually far in excess of any commercial loss they could have sustained from copyright infringement.

However, if the products in question have positive associations, especially if they appeal to children, instances of apparent brand copying almost always seem to go unnoticed, without any action or repercussions, except where health advocates report or publicise them, when the manufacturers may be forced to contact the ‘pirates’ of their trademarks, requesting them to desist.

So it was not surprising that when Philip Morris, manufacturer of Marlboro cigarettes, was preparing to sue the Australian government last November over its law on plain tobacco packaging, there was no word of any legal action or other complaint in Laos about a confectionery item on sale that strongly resembled a Marlboro cigarette pack, seen and photographed there at around the same time. In addition to the name and slogan in English the product carries text in Chinese, suggesting that it was made in China.

Figure9

Laos: a pack of confectionery in a pack strongly resembling a Marlboro cigarette pack, found on sale in Laos last year.

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