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In this issue, we examine progress – and some missed opportunities – in USA tobacco control on the 50th anniversary of the 1964 Surgeon General's report on smoking and health, together with new findings in the latest report. We also highlight several recent wins around the world in favour of public health and against the tobacco industry. In countries large and small, rich and poor, the industry fights every incremental step by governments to protect public health and implement measures in lines with legal obligations under the WHO Framework Convention on Tobacco Control (FCTC). Frequently, the industry is successful; if not in overturning policies entirely, at least in delaying implementation, or watering down provisions. However, an increasing number of countries are holding firm, strengthened by favourable court rulings guided by the legal weight of FCTC requirements.

All articles written by Marita Hefler unless otherwise attributed. Ideas and items for News Analysis should be sent to: marita.hefler@menzies.edu.au

USA: 50 years of tobacco control – remarkable progress, & missed opportunities

January 11 2014 marked 50 years since the publication of the landmark US Surgeon General's report on smoking and health. The report changed public perceptions of smoking in the USA, influenced tobacco control internationally, and set in train a long decline in smoking prevalence, from 42% of the American adult population in 1964 to 18% today. In the time since it was released, it is estimated that around 8 million premature deaths have been prevented as a result of tobacco control measures such as smoke free public spaces and public awareness campaigns about the dangers of smoking. However, in the same period more than 20 million Americans have died early from tobacco-caused diseases.

The first surgeon general report on smoking and health was released on 11 January 1964. 50 years later, the latest report, published on 19 January 2014, outlines how smoking is more dangerous than ever. The report can be downloaded from the US Surgeon General website http://www.surgeongeneral.gov/

A mock-up of the proposed corrective advertisements tobacco companies have agreed to run in national print and broadcast media for one year. Source: http://acscan.org/pdf/tobacco/ads/ex-c-print-ads.pdf via http://www.nationaljournal.com/health-care/here-s-what-it-looks-like-when-a-tobacco-company-says-i-m-sorry-20140113

While there has been undeniable progress, Professor Stan Glantz from the University of California, San Francisco notes that tobacco industry documents show the industry was terrified about the ramifications of the 1964 report, and was particularly concerned about a second report which was supposed to provide policy recommendations (http://tobacco.ucsf.edu/tobacco-companies-were-terrified-1964-surgeon-general-report-will-obama-finally-realize-their-fears). The second report was never written, and although smoking prevalence in the USA peaked in the 1960s, it wasn't until the 1980s that grassroots movements and meaningful policy action started, followed by a significant and sustained reduction in prevalence. The delay in developing and implementing strong policy responses to the epidemic is likely to have resulted in many more preventable premature deaths than would otherwise have occurred; it also gave the industry time to create doubt about tobacco's harmful effects and further delay effective action.

One of the major conclusions in the 50th anniversary Surgeon General's report, which was published on 19 January, is that the blame for all those premature deaths should be laid squarely at the feet of the industry: “The tobacco epidemic was initiated and has been sustained by the aggressive strategies of the tobacco industry, which has deliberately misled the public on the risks of smoking cigarettes.” Released by acting Surgeon General Borish Lushniak, the latest report adds several new conditions to the long list of smoking's disease effects, including liver and colorectal cancer, diabetes mellitus and rheumatoid arthritis. It outlines how the smoking-related disease risks for women have risen sharply and are now equal to men, and that the risks of lung cancer and chronic obstructive pulmonary disease are higher now than in 1964, despite people smoking fewer cigarettes. It links smoking with ectopic pregnancy and facial deformities in foetuses exposed to maternal smoking, macular degeneration and erectile dysfunction, and finds that secondhand smoke exposure increases the risk of stroke in addition to the established causal links to cancer, respiratory and cardiovascular diseases (the executive summary and full report can be downloaded at http://www.surgeongeneral.gov/library/reports/50-years-of-progress/index.html).

The report canvasses endgame strategies, including the potential role of e-cigarettes, but cautions that benefit is more likely only if the appeal, accessibility, promotion, and use of cigarettes are reduced. Tobacco advertising, promotion and sponsorship is unequivocally recognised as causing youth smoking, yet – consistent with USA opposition to advertising restrictions in the FCTC, based on court decisions interpreting advertising as constitutionally protected free speech – the report stops short of recommending a complete ban, opting instead for industry counter-marketing strategies. Also notable by its absence is any mention of the FCTC, which the USA signed in 2004 but has not ratified.

A week before the report was released, a 15 year civil racketeering case moved a step closer to resolution, with agreement reached between the USA government and four tobacco companies - Altria, RJ Reynolds Tobaaco, Lorillard and Philip Morris USA – for corrective statements in national media. A consent order for the agreement was filed for approval by US District Judge Gladys Kessler, who first ordered the statements in 2006 after finding that the tobacco companies had “marketed and sold their lethal products with zeal, with deception, with a single-minded focus on their financial success, and without regard for the human tragedy or social costs that success exacted.” The statements will be required to run in major print and broadcast media for a full year, and will also run in Spanish-language newspapers. The agreement may still be subject to delay if the tobacco companies pursue further appeals, a move which would be unsurprising to any industry observer.

Assuming the advertising does go ahead without further delays, not everyone is happy with the agreement: chairman Cloves C Campbell of the National Newspaper Publishers Association (NNPA), a federation of nearly 200 Black community newspapers, expressed shock and disappointment that the deal does not include any advertising through a Black print or broadcast company. In comments reported in the Sacramento Observer, he noted that the industry's targeting of African Americans is well-documented, and slammed the fact that the advertising will bypass Black media (http://sacobserver.com/2014/01/proposed-tobacco-settlement-excludes-black-media/). The industry's specific and tailored targeting marketing has resulted in a disproportionate burden of the harms of tobacco being borne by the African American community. Some have pointed out that given the NNPA's documented cosy relationship with tobacco companies across decades, perhaps NNPA media should run their own corrective statements.

Meanwhile, the Food and Drug Administration (FDA) has launched a portal for complaints about tobacco products. While it recognises the inherent danger of cigarettes, it requests complaints about ‘unexpected health problems’ and ‘health or safety problems beyond those normally associated with tobacco product use’. Given the widespread media coverage about new health conditions linked to cigarettes in the Surgeon General's report, and with few consumers aware of the full range of smoking's disease risks, defining what is ‘unexpected’ could be problematic. Complaint categories include ‘cancer-related problem’, ‘pregnancy or fertility problem, or harm to an unborn child’, and ‘other problem not listed’, among others. The portal can be accessed at http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm377225.htm#does.

Solomon islands: industry fails to derail tobacco control law

In December 2013, the Solomon Islands government passed a tobacco control law first drafted in 2010, despite strenuous attempts by the tobacco industry to derail its implementation.

Opposition came from the local British American Tobacco subsidiary, SITCO (Solomon Islands Tobacco Company). In a story repeated around the world when governments introduce legislation in line with their obligations under the WHO Framework Convention on Tobacco Control (FCTC), SITCO lobbied the prime minister and government, requested consultations with the ministry of health tobacco control taskforce and argued for the right to have input into the law, all of which would have constituted a breach of FCTC Article 5.3. The Solomon Islands ratified the FCTC in 2004. SITCO also submitted a 24 page response to the draft law, indicating it would consider legal action if its demands for revisions were not met.

The new regulation mandates pictorial health warnings to cover 70% of the front of the pack and 30% of the back, more than double the current combined total of 30% (although less than the 85% of the front and 100% of the back which was originally proposed.)

The law is a welcome development given that the country has no Quitline or other cessation support, and the only pharmacotherapy available is unsubsidised nicotine replacement therapy. In 2012, 56% of adult men, 26% of women and 41% of all adults were current smokers, together with nearly a quarter of all youth. With a population of only 550,000 the costs of tobacco-related disease are a significant threat to the Solomon Islands’ fragile economy.

Nepal: supreme court quashes tobacco industry appeal

The supreme court of Nepal has ordered tobacco companies to place 75% pictorial health warnings on all tobacco packaging. The requirement is contained in the Tobacco Product Control and Regulatory Act, which was adopted by the legislature in 2011, but had not been implemented. Eleven tobacco companies filed a writ against it, arguing that it was against international norms. The companies also argued that it was difficult to devote 75% of the pack to warnings and still include the brand name and product information.

In making the orders, the full bench of the court determined that the petition was against public health and the public interest and noted that the act is in line with the FCTC. It therefore declined to intervene. The order has been welcomed by the health advocates and the ministry of health and population, which estimates that there are more than 40 tobacco-related deaths each day in Nepal.

Israel: vending machine ban implemented

Cigarette vending machines are officially banned in Israel, effective from 1 January 2014 - two and a half years after the law was first passed. According to a Jerusalem Post report, the measure was resisted by vending machine companies on the basis that time was needed to adjust. Vending machine owners also appealed to the High Court of Justice, but the appeal was rejected on the basis that the law is important for public health, and to reduce the accessibility of cigarettes to minors. The measure is a welcome sign of progress in a country where reform is sorely needed. Although Israel ratified the FCTC in 2005, it continues to lag on many measures including comprehensive advertising, sponsorship and promotion bans, smoke free public places and graphic health warnings.

China: smoke free places planned from late 2014

There have been encouraging signs recently that the Chinese government is getting serious about reducing smoking.

A government circular in December instructed officials to refrain from offering cigarettes, or smoking while on official duties, and in public areas where smoking is banned. Officials were also reminded that using public funds to purchase cigarettes is not permitted. Smoking and exchange of cigarettes is ingrained in Chinese business culture and smoking is widely tolerated, especially outside of major cities. If properly enforced, the provisions in the circular could be a significant milestone in changing public acceptance.

A nationwide indoor smoking ban in public places is also in the works. Officials from the Chinese Centre for Disease Control and Prevention's Office of Tobacco Control and the National Health and Family Commission stated that planning is underway for the law, which they hoped could be rolled out by the end of 2014. The law may face political hurdles, given that state-owned tobacco companies contribute 7-10% of government revenue. However, the economic costs of the tobacco epidemic in China are increasingly recognised. A recent study by China's Central Party School noted that there would be significant economic benefits to reducing tobacco use which would outweigh the revenue generated.

Despite concerns about the political will to enact reforms, the value of BAT and Imperial Tobacco shares dropped in the wake of media coverage of the possible ban, by nearly 1% and 3%, respectively. The impact on investor sentiment is hardly surprising. With adult male smoking prevalence at over 50%, China is home to nearly one third of the world's smokers, and smoking causes one million deaths per year – a sixth of the global tobacco toll. Reducing the number of lives lost is likely to hit the industry's bottom line hard; the world Tobacco Atlas estimates the average profit for every death caused by tobacco is US$6000.

A properly enforced smoking ban could also curtail the significant potential for the market to grow further. Among female adults, prevalence is around 2%, a statistic the industry will likely have been eyeing as a significant opportunity, particularly among the country's growing middle class. Affordability of cigarettes has increased significantly in recent years, creating additional growth opportunities. In 2000, 100 packets of the cheapest cigarettes cost 14% of the average annual income. Today, it is less than 3%. Awareness of smoking's harms is low; only a quarter of adults have a comprehensive understanding of smoking's risks, and currently less than a third understands the risks of secondhand smoke.

China ratified the FCTC in 2006, but has to date implemented few of its provisions. The introduction and enforcement of a comprehensive national indoor smoking ban will be an important first step in the right direction.

UAE: Restrictions on shisha & Cigarette sales

The United Arab Emirates has adopted a range of measures to curb tobacco sales and limit areas where shisha smoking is permitted. In December, officials announced that a team of inspectors would be deployed to enforce fines of 500 diram (US$136) for violating bans on shisha use in public parks and beaches in the emirate of Dubai. The ban has been in place for some time, but was not previously enforced. Dubai is not the only emirate to place limits on shisha; in Abu Dhabi (site of the next World Conference on Tobacco or Health in 2015), restaurants and cafes in the Corniche area will be prohibited from serving shisha from February 2014. Elsewhere in the UAE, the city of Sharjah implemented a complete ban in December 2013 on sales of cigarettes by grocery stores and supermarkets in residential areas and near educational institutions.

This mock news article from 2013 satirised the fondness for shisha in the United Arab Emirates (source: http://www.panarabiaenquirer.com/wordpress/emirates-to-introduce-shisha-lounges-onboard-a380s/). However the UAE is set to make significant progress in tobacco control, with a tightening of restrictions on both shisha and cigarettes.

Netherlands: change in tobacco control organisations

The Dutch expert centre on tobacco control STIVORO has been discontinued from January 2014, a result of several decisions made by the Dutch government and other funders.

STIVORO was founded in 1974 by the Dutch Cancer Society, Lung Fund and Heart Foundation. From 1991, the Dutch Ministry of Health also provided yearly grants to the organisation. STIVORO became known for large mass media campaigns, a strong scientific basis of continuous monitoring studies, smoking cessation courses and operating the national quit line.

Since 2010, STIVORO had already been forced to reduce from a full time operation with the equivalent of 38 full time staff in 2010, to just six in 2013. In 2010, the ministry of health decided to stop all smoking education mass-media campaigns, as well as direct funding for the quit line. In 2011, the ministry further reduced funding for public health information about smoking, and transferred the remaining amount from STIVORO to the Trimbos Institute, the national centre of expertise on mental health and addiction. The ministry wanted a comprehensive lifestyle approach, and opted for the integration of tobacco with other addictions.

Apart from the government decisions, in 2010 the Dutch Cancer Society, Lung Fund and Heart Foundation announced investment in a new approach to tobacco control and that therefore they would withdraw their funding for STIVORO from 2014. Throughout 2013, the remaining small team of STIVORO focussed on continuing to build the knowledge base of policy measures and tobacco industry tactics.

Because the original individual founders of STIVORO wanted to maintain the expertise and distinct profile of tobacco control within a broader alliance of health organisations, they established the Alliance Smokefree Holland. A number of employees from STIVORO have continued their work at this new tobacco control organization‘Alliantie Nederland Rookvrij!’ (Alliance Smokefree Holland).

Currently, 33 Dutch organizations have joined this Alliance and more are expected to follow. With this backing, it is hoped the Alliance will be able to continue the vital work of taking on the tobacco industry and, when needed, the Dutch government.

Gera E Nagelhout

Maastricht University and Alliance Smokefree Holland, the Netherlands

gera.nagelhout@maastrichtuniversity.nl

Dewi Segaar

Alliance Smokefree Holland, the Netherlands

Australia: end of an era as ash closes

After nearly 20 years, Action on Smoking and Health Australia (ASH) ceased operation at the end of 2013. Its closure marks the end of a chapter in Australia's history that has seen smoking rates at their lowest-ever levels, and continuing to fall, with every policy step resisted by the tobacco industry.

The success of ASH can be measured in part by how rapidly the tobacco control landscape has changed: virtually all indoor public spaces are now smoke free, there is a comprehensive ban on tobacco advertising, smoking is comprehensively denormalised, and the tobacco industry is widely reviled in Australian society. When ASH started in 1994, few of these measures were in place, and scarcely any organisations were working on tobacco control issues. Today, reducing smoking is a key priority of public health, with many government and non-government organisations dedicating resources and staff to all aspects of tobacco control.

In recent years, ASH has continued to extend the scope of tobacco control in Australia. Among its many successes was recent progress in introducing laws to protect people in multi-unit housing from secondhand smoke, tackling political donations, reducing duty free allowances and spearheading a growing international movement for tobacco divestment.

The organisation has been an invaluable support to the tobacco control community in Australia, providing resources and research for policy and legislative changes, media advocacy, and monitoring and exposing the tobacco industry. Many ASH resources were used to develop international resources and toolkits in low and middle income countries including tobacco-free campuses, tobacco-free sporting and mega events and protecting health policies from tobacco industry interference under the WHO Framework Convention on Tobacco Control (FCTC) Article 5.3.

The work of ASH helped put Australia at the forefront of international tobacco control. The ASH website and the various resources and toolkits are archived and available at http://pandora.nla.gov.au/tep/119321.

Japan: jt moves to e-cigs, snus amid confusion over nicotine content

In Japan, as in other countries, lack of regulation is causing confusion among consumers about the nicotine content of e-cigarettes. Between June 2007 and July 2010, the National Consumer Affairs Center of Japan (NCAC) received 309 queries regarding the safety of e-cigarettes. To provide safety information for consumers, NCAC tested the ingredients of randomly selected e-cigarettes (45 flavours of 25 brands) from May to July 2010. All of the e-cigarettes that were selected were labelled as not containing nicotine on the packaging, but the NCAC findings showed that many (15 flavours of 11 brands) actually did contain nicotine.

The Ministry of Health, Labour and Welfare expressed the view that it was doubtful that these e-cigarettes could be used as unapproved medicine because orally-ingested nicotine-containing products must be categorised as medical equipment or medicine under the Pharmaceutical Affairs Law. The health ministry warned dealers not to sell these nicotine-containing e-cigarettes and to recall the products. It also requested local governments to implement monitoring and provide information about e-cigarettes. The Japan Electronic Cigarette Industries Association was established in October 2010; however, progress towards implementing safety standards and business compliance regulations for the e-cigarette industry has been slow.

Meanwhile, Japan Tobacco (JT), which has the exclusive right to manufacture tobacco products granted by the Japanese government based on the Tobacco Business Law, has been expanding into the e-cigarette and smokeless markets. In May 2010, JT released a new snuff product called Zero Mint Style. In December 2011, JT, through Japan Tobacco International (JTI), acquired the commercial rights to sell Ploom, a well-known American e-cigarette which contains nicotine, outside the United States. It commenced online sales in December 2013. And in August 2013, it also started selling Swedish Snus.

Kaname Ishiguro

CDC International Corporation, Japan

kaname_ishiguro{at}cdc-kobe.com

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