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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

World conference: a watershed event?

The 15th World Conference on Tobacco or Health (WCToH), held in Singapore from 20 to 24 March, opened with a fiery address by Dr Margaret Chan, Director-General of the WHO. Describing the international tobacco industry's never-ending battle against health, Dr Chan starkly outlined how ‘tactics aimed at undermining anti-tobacco campaigns, and subverting the Framework Convention, are no longer covert or cloaked by an image of corporate social responsibility. They are out in the open and they are extremely aggressive’. Encouraging governments and members of civil society to stand shoulder to shoulder, she likened tobacco to a drive-by shooting which kills innocent bystanders, and expressed her hope that the conference would be a watershed event which would tip the balance back in favour of tobacco control against the increasingly aggressive tactics of the ‘despicable’ tobacco industry.

Delegates took up the challenge: the behaviour of the tobacco industry was a recurring theme. With a fourfold increase in litigation against public health measures between 2005 and 2011, numerous presentations detailed the ways in which the tobacco industry is taking off its gloves in the fight against governments for simply doing what is required of them under the Framework Convention on Tobacco Control (FCTC). As trade agreements have been central to industry legal strategies, several speakers emphasised the need to carve tobacco out of trade agreements, to ensure they can't be used to undermine the FCTC and national sovereignty.

Few tobacco control policies have attracted as much concern from the industry as Australia's recent move to plain packaging, passed into law at the end of last year. Interest in how the policy was developed, and the industry challenge to it, was high.

The analogy of the tobacco industry as a disease vector was extended with the observation that the vector is changing in response to the success of tobacco control strategies. When a vector changes we use new treatments, and the tobacco control community needs to do likewise. More importantly, the need to eradicate the vector rather than merely controlling it was raised: the ‘tobacco endgame’ was a topic of several sessions. At the opening ceremony, one delegate proposed that if we are serious about ending the tobacco epidemic, we should plan so that the year 2030 could be the final WCToH. Nearly 90% of the world's population lives under governments which are signatories to the FCTC—can the tobacco control community match the ability of the vector to mutate and exploit markets where FCTC implementation is weak or governments are not yet signatories?

With more than 2600 delegates from 124 countries in attendance—including record participation from low and middle income countries—there was plenty of focus on tobacco not only as a health problem, but also as a development issue. The myth of the economic benefits of tobacco production was smashed repeatedly; tobacco does not just cause death, disease and poverty for its users, it also creates poverty for growers. The cloak of respectability of the tobacco industry was ripped away by multiple presentations showing how, for many subsistence farmers lured by easy credit and the promise of guaranteed returns, tobacco is in fact a poverty trap. Examples were heard of shocking labour conditions, including child labour, from India, Malawi, Kenya and Cambodia, among others—along with accounts of environmental degradation.

Social media was another hot topic—both the need to monitor tobacco industry activity in social media, and also the need to ensure that tobacco control effectively utilises its potential. There was only one presentation about social media at the previous WCToH, in Mumbai in 2009, which was slotted away with sports sponsorship because it had not seemed to fit in anywhere else. In 2012, the conference had numerous sessions on this rapidly evolving topic. There is still a long way to go, however. In one session, the number of people who used social media was in inverse proportion to the number of years' experience in tobacco control. Clearly, the tobacco control community needs to find a way to effectively bring together expertise in social media and the collective wealth of tobacco control experience.

Finally, in the closing plenary session, internationally renowned epidemiologist Sir Richard Peto outlined just how effective simple strategies can be with the ‘triple, halve, double’ rule: triple the price of cigarettes, to halve consumption, which will double the tax yield to government. Adding this to the many other important, evidence-based guidelines shared at the conference, delegates returned home re-energised in the knowledge that while the tobacco pandemic may be unique in history for its sheer size and duration, the battle to overcome it is winnable. It is reasonable to expect that when the 16th WCToH convenes in Abu Dhabi in 2015, delegates will have new victories over Big Tobacco to celebrate.

MARITA HEFLER

University of Sydney, Australia

marita.hefler{at}sydney.edu.au

Figure1

World Conference: a colourful display at the opening ceremony of the world conference in Singapore in April.

India: court rules that nicotine is poison

A divisional bench of the Punjab and Haryana State High Court in Chandigarh recently issued a historic order stating that chemical nicotine (as opposed to naturally occurring nicotine in tobacco) is a poisonous substance. The court, which has jurisdiction over the states of Punjab and Haryana and the union territory of Chandigarh (the city that serves as the capital of the two states), directed that chemical nicotine cannot be used as an additive to any other material. It also ordered the governments of Haryana, Punjab and Chandigarh to constitute a special task force to monitor and implement the court's directions. The decision is believed to be a world first.

The writ petition differentiated between naturally occurring nicotine in tobacco leaves and nicotine extracted from the plant, an insecticide and a poison which can kill a person with a single dose of 40–60 mg. The petition was filed last year by Hemant Goswami of the Burning Brain Society, a non-governmental organisation based in Chandigarh, and was supported by the National Tobacco Control Programme.

The judgement had an immediate effect on hookah/shisha (water pipe) bars all over the country, as it gave teeth to administrators to ban them or close them down. Many products, including the tobacco used in hookah bars, are laced with chemical nicotine, which makes them more addictive. In addition, the nicotine is extracted by using solvents, including toxic and in some cases carcinogenic chemicals.

Tobacco has remained a legal product mainly because the leaves are naturally occurring and so unregulated. However, nicotine in chemical form, freely available in solid and liquid form, is a processed chemical. India's Drugs Act regulates all chemicals that are extracted from natural substances and which may be used in any drug formulation. The writ petition in the High Court therefore emphasised that the material used in the hookah/shisha was not naturally occurring tobacco, but rather nicotine as a chemical, thus requiring regulation as a drug and/or poison, and being banned from public sale.

The High Court's statement described the abuse of nicotine in chemical form as a serious problem, calling for appropriate action to implement the mandate of Article 21 of the Constitution of India (regarding the protection of life and personal liberty). It further stated that Haryana, Punjab and Chandigarh were free to take action against hookah bars as nicotine in chemical form was a poisonous substance under the Insecticides Act, 1968 and the Environment Protection Act, 1986. Furthermore, as nicotine is classed under the category of ‘drugs’, hookah bars must possess appropriate drug manufacturing licences. However, none of the hookah bars raided in Haryana, Punjab and Chandigarh possessed the requisite license, purchase or sale documents for nicotine. Consequently, legal action was initiated against them. Violation carries a minimum penalty of 3 years imprisonment and a fine.

The court's decision provided the legal authority for dealing with the proliferation of hookah bars in Haryana, Punjab and Chandigarh, which has worried health activists recently. In addition to the closure of more than 60 hookah bars in the two states and Chandigarh, the decision has other important implications. It is thought that some cigarettes may also contain added nicotine in chemical form. If and when firm evidence of this becomes available, shops selling cigarettes with chemical nicotine may follow hookah bars into closure.

The judgement is more than a blow to companies which attempted to mislead Indian consumers about the dangers of extracted nicotine; it is also a serious warning to the wider tobacco industry about attempting to keep smokers addicted, highlighting an area of policy that other countries will now wish to explore.

SONU GOEL

Postgraduate Institute of Medical Education & Research, Chandigarh, India

HEMANT GOSWAMI, RANA J SINGH

sonugoel007{at}yahoo.co.in

China: tobacco research prize nomination sparks protests

The nomination of a tobacco industry scientist's work for a prestigious science prize caused an unprecedented row among the scientific and health communities in China recently. In the past, the state tobacco monopoly's activities have not been the focus of widespread criticism, at least in public. However, the nomination in March of a project claimed to have boosted sales and improved the quality and marketability of Chinese cigarettes was the subject of 33 out of 58 objections about 19 candidate projects, lodged with the organisers in a 40-day period for public comment. The office administering the 2012 national science and technology progress award, which forwards objections routinely to nominating agencies for their comment, was then informed that the state tobacco monopoly was withdrawing its candidate.

Professor Yang Gonghuan, former deputy-director of the Chinese centre for disease control and prevention and now based at the Peking Union Medical College's school of basic medicine, published an open letter to science minister Wan Gang in April, calling on the ministry of science and technology to ban tobacco research from being considered for national science awards. China's leading science website, ScienceNet.cn, also took up the cause, inviting site-users to add their names to a similar demand.

Last year, researchers protested against the election of a tobacco scientist to the prestigious Chinese academy of engineering, whereas previous awards to the same scientist for his low tar research work, and the election of another tobacco scientist to the academy, had attracted little public comment.

Professor Yang interpreted the recent protests as demonstrating a new level of awareness about tobacco among scientists and society as a whole in China. Even though the tobacco monopoly has not tended to contest scientific findings about tobacco and disease, nor plumbed the depths of western companies' marketing malpractices, concern about tobacco has increasingly been reported in recent years. Chinese tobacco manufacturers have attracted criticism for emulating some of the youth-friendly marketing ploys of their western counterparts, and questions have been raised in the media about tobacco factories sponsoring local schools.

However, the widespread and open criticism of the recent science prize nomination does seem to indicate a new level of awareness of tobacco control issues and a feeling of greater freedom to demand that the interests of public health should take precedence over those of tobacco. This is especially important in a country where a quarter of the world's population smokes a third of the world's cigarettes—and later pays the price in premature death and disease.

Argentina: graphic picture health warnings

Following the strong lead set by other countries in the region, including Brazil and Uruguay, the government of Argentina announced in April that pictorial warning labels would start to appear on cigarette packs from 15 June 2012. They will meet the minimum standards set out in guidelines to the FCTC, requiring 50% of both the front and back of packs to carry a picture and text. The 10 messages that will appear in Spanish in rotation include: Smoking causes cancer; Smoking causes addiction; Smoking causes heart and respiratory disease; Pregnant women who smoke cause irreparable harm to their children; Smoking causes emphysema; Smoking causes sexual impotence; and Smoking may lead to leg amputation.

In addition to the disease and toxicity warnings, one side of the pack must display a toll-free telephone number that provides smoking cessation help.

Argentinian health advocates are pleased that the government issued the regulation to implement the new warning scheme within the period established by the country's tobacco law.

Ecuador: 60% pack warnings

Six picture-based warnings are to appear on the lower 60% of the front and back of cigarette packages from 15 July this year. In addition, qualitative information about toxic emissions will be required to appear on 70% of one side panel; and misleading descriptors, including ‘light’ and ‘mild’, have been banned. Ecuador joins Argentina (see above), Bolivia, Brazil, Uruguay, Venezuela and Costa Rica among the countries in Latin America in adopting graphic tobacco pack warnings, making a global total of around 50 countries that already have them on tobacco packs, or have passed legislation to implement them.

Figure2

Ecuador: new health warnings include one that translates as, ‘Smoking will cause a slow and painful death’ and another that warns, ‘Smoking will wrinkle and damage your skin’.

Costa Rica: tobacco control law is passed

Costa Rica has become the latest Latin American country to enact a comprehensive tobacco control law, despite tobacco industry attempts to prevent it. On 27 February this year, the law was passed by a vote of 45 members of parliament in favour to two against, and less than a month later, on 22 March, was signed into law by the country's president.

The new law requires bars, restaurants and public places to be 100% smoke-free, increases tobacco taxes and severely restricts the promotion of tobacco products. It also prescribes pictorial warning labels to cover 50% of both the front and the back sides of cigarette packs.

After the successful vote in parliament, 10 deputies, including some known to be sympathetic to the tobacco industry, formally challenged the new law's constitutionality with an approach to the supreme court, but the appeal failed. The move was seen as the latest of many attempts by tobacco companies, principally British American Tobacco and Tabacalera Costarricense, a subsidiary of Philip Morris, to try to stop or delay public health measures in Costa Rica. In the 1990s, when the country proposed an advanced tobacco control bill, the companies campaigned for a significantly weaker tobacco law, passed in 1995. Following that victory, they secretly hired scientists to produce studies playing down the effects of passive smoking, and covertly negotiated with health officials and politicians to implement weak voluntary advertising measures to pre-empt more restrictive legislation. In a familiar move wherever effective smoke-free legislation is announced, the industry employed tactics of misinformation in the media and manipulation of the hospitality industry to oppose the measures.

However, in a fitting victory for a country that is among the world's most advanced for environmentally sound governance, where only 14% of adults smoke, and 93%, including many smokers, support strong anti-tobacco laws, health, not tobacco, eventually won the day.

Ukraine: health ministry not consulted on plain pack challenge

Tobacco control advocates are still trying to find out how the government of Ukraine decided recently to file a complaint in March to the World Trade Organisation (WTO) accusing Australia of violating intellectual property and free trade laws. A government employee revealed that the country has not traded any tobacco products with Australia since 2005 or even earlier. To be taken seriously, it is thought that a complaint about violation of trade would have to demonstrate that trade between Ukraine and Australia in tobacco products would be damaged. The Australian law will permit only plain packs, with minimal brand names in a standard typeface, to be sold from December this year.

Of equal interest is that the letter requesting action by the WTO appeared not to have been written by a citizen of Ukraine, being composed first in English and then in Ukrainian. The government source also claimed that the decision to challenge the legislation was made in secret within Ukraine's ministry of economics; contrary to regular practice, it was not cleared first with the health ministry.

Honduras, a tobacco exporter, also launched legal action recently, and was followed by a dozen more countries which have signed up to the legal complaints including Brazil, Canada, the EU and Indonesia. According to WTO, third-party countries often sign up to legal complaints, but this does not necessarily indicate their opposition. Under the trade body's rules, Australia is expected to go before a WTO court over the complaints.

From the international tobacco industry, Japan Tobacco International and Imperial Tobacco have joined Philip Morris International and British American Tobacco in launching lawsuits against the Australian government, accusing it of illegally confiscating their brands. They claim that there is no scientific evidence to show that plain packaging will reduce smoking rates. Philip Morris International and British American Tobacco, the two largest tobacco companies outside China, admitted advising several countries that have complained about Australia's plain packaging laws, and are believed to be providing legal support for this challenge to a country's ability to protect public health.

Argentina: farmers sue PM over birth defects

A major new lawsuit has been filed against Philip Morris (PM), several subsidiary companies and other firms, including Monsanto, engaged in tobacco growing in the Misiones province of Argentina. The case concerns agricultural chemicals that are alleged to have caused birth defects in the children of tobacco farmers. Some 14 000 metric tons of tobacco is imported into the USA from Argentina every year, most of it grown in Misiones. The complaint, filed in a court in the US state of Delaware, sets out strong allegations against PM and the other companies, alleging that they ‘wrongfully participated in the promotion, manufacture, design, sale, distribution and use of certain reproductively toxic herbicides, pesticides, insecticides and other chemical products which were used by the parental Plaintiffs in the cultivation of tobacco and other crops’.

The farmers say the tobacco companies asked them to use herbicides, pesticides and other toxic products, often in large concentrations, assuring them that the chemicals were safe. They claim that the companies knew, or should have known, of the significant risk of children on the farms being born with severe birth defects, including cerebral palsy, epilepsy, spina bifida, intellectual disabilities, metabolic disorders, congenital heart defects, missing fingers and blindness. Most farmers in Misiones used Roundup, a glyphosate-based herbicide made by Monsanto, to kill weeds and clear tobacco fields, according to the complaint.

The farmers also claim that the tobacco companies asked them to replace the native tobacco plants with a type used in PM's cigarettes, which required more pesticide use, urging them to use excessive amounts and failing to warn them of the dangers or to provide them with information or protective equipment. The farms concerned are mostly small, with family members exposed to chemicals used on crops as they work, travel through and grow food or play on the land planted with tobacco. Pesticides also contaminated wells and streams used by the families for drinking water, cooking and washing, the farmers claim.

Figure3

Spain: part of an advertisement from Pacha, magazine of the Pacha nightclub chain, advertising the smoke-free policy in its clubs.

Spain: young, fashionable—but that awful smell of smoke…

At this time of year, people in the northern hemisphere are enjoying summer holidays and for many, especially in northern Europe, a sunny beach and a spot of nightclub life are part of their relaxation and fun. The sizeable industry that provides their entertainment has undergone significant changes lately, none more obviously than up-market leisure clubs.

Amazingly, tobacco companies have managed to survive and prosper for over half a century since overwhelming scientific evidence about the disease their products cause began to accumulate. When near-saturation promotion of cigarettes associated them with all things diametrically opposite to the realities of smoking, the industry got off lightly on another, noticeable reality of smoking: the noxious, lingering smell that smokers share with anyone who happens to be nearby while they are smoking.

Now some sort of tipping point seems to have been reached. In the past, the fashion industry and the massive leisure industry catering for ever larger numbers of young people with disposable income almost everywhere, discreetly glossed over this problem. The businesses were just too dependent on tobacco—or so they thought. Now, following the advent of hugely successful and popular smoking bans in public places, some fashion leaders are breaking ranks. The latest is Pacha magazine, published by the eponymous chain of nightclubs, among the world's most famous, which is based in the popular Spanish holiday island of Ibiza.

Pacha is nothing if not a global lifestyle brand, the very sort that tobacco companies love to be seen with, and whose customers they would love to make their own. But following the recent implementation of comprehensive Spanish smoke-free legislation, the company's magazine reported that in addition to establishing outdoor smoking areas in its nightclubs, the company had commissioned a new range of fragrances from New York perfume makers. While this was primarily to cover up the smell of hot human beings that can be all too discernible now that the smoke has cleared inside the clubs, a prominent article in Pacha clearly recognised that another smell can be much worse. ‘Reeking of cigarettes after a night on the tiles was to be expected’, it began, referring to the situation before the ban. ‘Even if you were a non-smoker it wasn't easy avoiding the giddy haze of cigarette fog in any social situation.’

How good to see that the top end of the leisure industry no longer feels afraid to tell it like it is about tobacco.

Figure4

World: the poster for this year's World No Tobacco Day, which took place on 31 May 2012. The WHO selected ‘tobacco industry interference’ as the theme, appropriately, as can be seen frequently from stories in the News Analysis section in Tobacco Control.

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