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In terms of human misery, tobacco is a giant. One of the world's leading causes of mortality and ill-health, it is a manufactured epidemic which enriches a few at the expense of millions. From cultivation to consumption, the negative effects of the tobacco industry outweigh the positive at all steps in the production process. Yet, like a reviled, disgraced but wealthy relative at a wedding, it continues to be politely tolerated – even welcomed – by otherwise respectable organisations willing to benefit financially from its malevolent noblesse oblige. ‘Social responsibility’ and reputation management initiatives are essential proxy advertising for an industry which regularly features in consumer survey ‘worst reputation’ lists. In this issue we examine two such initiatives: an industry announcement of an intention to adhere to (already well-established) legal standards regarding child labour, and acceptance by one of the USA's largest humanitarian charities of tobacco company donations. The cognitive dissonance inherent in praise and endorsement of these initiatives is striking, given the extent to which the industry profits from youth smoking, as well as the enormous annual death toll from its products – far in excess of any other natural or human-caused disaster.

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

WORLD: INDUSTRY CONFRONTED WITH CHILD LABOUR ISSUE

This story is also online at http://blogs.bmj.com/tc/2015/01/27/tobacco-industry-confronted-with-child-labour/. In 2014, the tobacco industry was confronted with the revelation of child labour on US tobacco farms, detailed in a well-researched 139 page report published by Human Rights Watch (HRW). The USA is not alone; most major tobacco producing countries use child labour in tobacco growing. In other words, almost no cigarette can be guaranteed to be free from child labour.

The US Department of Labor lists 17 countries which use child and forced labour in tobacco and bidi production. Although extensive, the list is incomplete – for example, the United States itself is not included. Prior to the 2014 report about US tobacco farms, research reports on Kazakhstan in 2010 by Human Rights Watch and Malawi in 2009 by Plan Malawi attracted worldwide media coverage.

Despite the known scale of the problem, every time a new report is published tobacco companies react with apparent surprise, and depict the problem as an isolated local rather than global issue, detached from the structural power relations within which the industry operates. In the wake of the HRW report on Kazakhstan, Philip Morris said it was ‘grateful’ that the NGO raised the issue, despite the fact that it sent officers to its contract farms on a regular basis.

The child labour issue is nothing new for the tobacco industry, as can be easily researched with the internal documents database. In 1999, British American Tobacco (BAT) for example showed its awareness of the problem when one of its representatives discussed how it could best ‘get value for [its] cash and time contribution’ to the International Tobacco Growers' Association (ITGA). “I would in particular very much like them to delve more into the child labour and WHO issues…Otherwise what is the point of having the membership and paying the money?” wrote Shabanji Opukah, BAT's corporate social responsibility manager. Fifteen years later, little appears to have been done to find and implement sustainable solutions to improve tobacco workers' lives.

On December 10th, 2014, tobacco companies through their Eliminating Child Labour in Tobacco Growing (ECLT) foundation announced a pledge to end child labour in their supply chains. In particular, they announced a commitment to adhere to international labour laws and children's rights' conventions that prohibit hazardous work for children under 18 – commitments that have already been signed by most countries.

Reuters published an article that boils down to HRW praise of the pledge as a ‘first time’ thing, lending legitimacy to the move and tobacco industry as a whole, although it noted that significant gaps remain and some key players such as China National Tobacco Corporation and Reynolds Tobacco are not ECLT members. At the end of December, a New York Times editorial also discussed the issue. While putting an emphasis on the need for the US government to pass a law that prohibits the work of children under 18 in tobacco, it praises the tobacco industry. Among others, the article says: “Given Big Tobacco's shameful history of marketing cigarettes to children, it is noteworthy that the industry is willing to do the right thing in the case of child workers.”

While any move to improve its business practices is welcome, given its history, it seems the tobacco industry is more focused on doing the right thing for its public image than safeguarding the rights of child workers. The industry is particularly keen to embrace voluntary agreements which provide good public relations, while being unenforceable. With articles like the New York Times editorial, big tobacco succeeds in being seen as part of the solution rather than the problem. This obscures the fact that tobacco industry is extremely monopolised, has a record of collusion and suppression of leaf prices, interferes with policy development and invests in NGOs such as ITGA, ECLT and many others in tobacco growing countries, in order to be seen as a good corporate citizen.

For many farming households in developing countries, tobacco production is a precarious livelihood, overshadowed by debt and the threat of poverty. If smallholder farmers – who produce much of the world's tobacco leaf – do not receive enough money in exchange for their tobacco, they have little choice but to enlist their children to work. Human Rights Watch, in its otherwise well-researched report, fails to analyse the structures and power relations of the global leaf market, and the role of tobacco industry financing in encouraging the expansion of tobacco cultivation.

Lay people, and unfortunately also development professionals, may believe that voluntary industry pledges are a shortcut to improving human rights and reducing poverty. Companies seem to react quickly while governments take longer to develop, debate, pass and implement laws. However, examining the history of tobacco industry pledges regarding child labour, little has changed in the past 15 years. To achieve sustainable human rights improvements, properly-enforced laws that make corporations accountable and change power relations between workers and companies are needed, rather than voluntary industry codes.

It is noteworthy that the industry found it necessary to pledge to abide by national and international laws. Do they really deserve congratulations for trying not to break the law?

Laura Graen

For Changemakers, Germany

www.forchangemakers.com

graen{at}forchangemakers.com

USA: RED CROSS TOBACCO FUNDING RISKS GLOBAL BRAND

This story is also online at http://blogs.bmj.com/tc/2015/01/20/american-red-cross-tobacco-funding-risks-global-brand/

The American Red Cross is under increasing pressure to refuse tobacco industry donations, to bring it into line with guidelines of the International Federation of Red Cross and Red Crescent Societies and most of the 189 national affiliates. Accepting tobacco funding is in clear breach of the first of the seven Fundamental Principles of the International Red Cross and Red Crescent Movement – Humanity, which includes the statement: “[the Movement's] purpose is to protect life and health and to ensure respect for the human being”.

The principles and rules for Red Cross and Red Crescent Humanitarian Assistance state in regard to relations with the external actors: “National Societies and the International Federation shall enter into partnerships with private sector actors that…have a positive image, and a track record of good ethical behaviour” and “…shall not accept donations from sources which risk the image or reputation of any component of the Movement”. On both counts, the association with Altria Group fails.

The value of partnering with the Red Cross is clearly outlined on the International Red Cross website, which includes among the benefits to corporations: demonstration of corporate social responsibility, and “that consumers – both current and potential – have a more positive image of a company that supports a cause they care about.” The American Red Cross website recognises Altria Group on the webpage of its Annual Disaster Giving Program (ADGP), which notes that “…ADGP members are valued Red Cross donors. They receive a high level of recognition and access to Red Cross information and leadership.” About Altria Group, it says: “Altria and its companies…have a long-standing relationship with the American Red Cross; we share a tradition of providing support to people and communities in times of need”. The millions who have lost family members to smoking, hooked by Marlboro's seductive advertising while they were kids, may disagree.

A spokeswoman for the American Red Cross Laura Howe, was quoted in a Reuters report of the issue that the organisation was “happy to accept any funds that support its efforts to assist disaster victims.” The double standards implicit in the statement is striking, given the annual death toll from tobacco products in the USA is over 400,000 – far in excess of any other natural or human-caused disaster. By way of comparison, Altria Group donated US$1 million to assist with Hurricane Sandy relief efforts, for which the US death toll was 117.

While the American Red Cross won't engage in cause marketing or imply an endorsement of a tobacco product, the value of the association to Altria Group is as clear as would be the case if the Red Cross allowed its logo to be merged with the Marlboro logo.

ISRAEL: UNI CUTS TOBACCO LINK AFTER CANCER ASSOCIATION PROTEST

In January, the Israel Cancer Association (ICA) took an unequivocal stance against plans by Tel Aviv University (TAU) to hold a Philip Morris-sponsored event. According to a Jerusalem Post report on 4 January (http://www.jpost.com/Israel-News/Health/TAU-cancels-Philip-Morris-event-following-pressure-from-cancer-organization-386621), TAU had an agreement for Philip Morris to provide scholarships to School of Marketing students. An event had been planned for 6 January for students to meet senior managers at Philip Morris and learn more about the company. The ICA, which last year provided 600,000 Shekels (approximately US 152,000) in research grants to TAU, called for the event to be cancelled, and advised it would freeze all new research grants if the event proceeded. The ICA president, Professor Eliezer Robinson noted that it would be unthinkable for ICA to help TAU researchers fight cancer while on the other hand TAU strengthens and encourages the tobacco industry.

INDONESIA: WARNINGS NEED STRONGER ENFORCEMENT

As reported in the September 2014 edition of News Analysis, pictorial health warnings (PHW) on cigarette packs in Indonesia were due to be implemented in June 2014. The Indonesian government approved the warnings, after a lengthy process, under Article 114 of the Health Law No 36/2009, with 18 months lead-in time from approval to implementation.

An Indonesia cigarette pack with the mandated pictorial health warning

A Mild branded cigarette case, available after mandated pictorial health warnings came into force]

Considering Indonesian tobacco companies have been exporting cigarette packs with pictorial warnings to neighbouring countries for many years, 18 months was extremely generous to the tobacco industry before mandating Indonesians receive the same information as other people in the region about smoking's dangers. Nonetheless, by 24 June, only about 13% of brands were reported to be compliant with the new law. The tobacco industry was then given a further two months to comply, bringing the transition period to a total of 20 months.

The Faculty of Public Health, University of Indonesia coordinated a survey in the last week of August 2014 – the end of the extended implementation period – to assess the progress of compliance at points of sales (POS). The survey was done in 54 subdistricts of seven cities of seven provinces in Java, including the capital Jakarta and less densely populated outer islands. The National Commission for Child Protection together with researchers from universities in Banda Aceh, Pontianak, Makassar, Jakarta, Semarang and Surabaya surveyed 525 POS. Each covered 10 randomly selected POS in five categories: distributor to retailer, supermarket, minimarket, kiosk and vendor.

No cigarette brand variants assessed in the survey fully complied with the pictorial health warning requirement at all POS sites. Between 40–60% of brand variants were non-compliant (had no PHW at all), and 4–5% were partially compliant (had a PHW, but with other violations of the law such as excise stamps obscuring the warning on the packs). In addition to pictorial health warnings, information is also required on all packs to advise that there is “no safe level” of tobacco use and that cigarette smoke “contains more than 4,000 hazardous chemicals and more than 43 cancer-causing agents”. No domestic brands of the top five manufacturers provided this information.

Five of the largest tobacco companies, which collectively control 90% of the market, showed low compliance. Bentoel/British American Tobacco (BAT) was the worst offender, with non compliance between 63–90% in six of the survey sites. BAT had distributed a notice to retailers providing misleading information that production of packs with new PHW would only begin after June 24, and retailers can continue selling old stocks without a deadline. Even shops located right outside tobacco factories in Surabaya were selling packs without PHW.

The packs that did carry the new pictorial warnings created strong reactions from smokers, consistent with the evidence from other countries. The pattern was similar in all cities, with the most common reaction to look for packs with no PHW (52–96%), or choose the least scary picture – one which shows a “smoking man” with a skull background (68–95%).

In Makassar, more than 30% of smokers expressed feelings of disgust, fright, thoughts of buying single sticks, looking for non-PHW packs in other POS, no desire to smoke, perceived change in taste, and “accused” the industry of reducing the amount of cloves and flavouring in the cigarettes. The head of Gudang Garam distributors in Makassar had earlier expressed concern that the PHW had an impact and was seeing declining sales. Similar smoker responses were recorded in other survey sites.

Smokers negatively affected by PHWs resorted to several ways of obscuring pictures on packs, such as covering them with stickers showing attractive women, asking the shopkeeper for a dark tape to cover the PHW, putting the pack inside a case and even discarding the pack altogether in favour of alternatives. Sampoerna's “A Mild” branded metal cases were found available for sale after June 24.

Such consumer reactions suggest that most Indonesian smokers previously were not fully aware of the many dangers of tobacco use. The strong reactions the PHW evoked are consistent with those of smokers everywhere, and provide positive feedback that PHW are effective, even among those heavily addicted. This explains why the tobacco industry strongly opposes PHW policy in Indonesia in the same ways it opposes effective tobacco control measures globally; first by filing a case in the Constitutional Court, then intentionally misinterpreting the effective date of implementation, and now delaying compliance even after the generous 20 months after the deadline for full implementation.

The Food and Drug Authority responsible for enforcement has given the industry ample time and warnings for compliance. It is time for the government to take serious action against the industry's prolonged and continuing violations of the regulations which, if implemented properly, will set Indonesia on the path to reversing the epidemic for which the country pays such a high health, social and economic price. This article is online at http://blogs.bmj.com/tc/2015/02/08/indonesia-tobacco-pack-warnings-need-stronger-enforcement/.

Widyastuti Soerojo

Southeast Asia Initiative on Tobacco Tax

wsoerojo{at}gmail.com

SOUTH KOREA: PRICE HIKES & NEW SMOKE FREE AREAS

The start of 2015 saw what may be a new era in tobacco control in South Korea, with new measures to reduce smoking prevalence to around 20% by 2020. From January 1, the price of a packet of cigarettes has increased by 80% to 4500 won (approx US$4.15). Previously, South Korean cigarette prices were the cheapest in the OECD and had remained unchanged for a decade, a statistic reflected in the adult male smoking rate of 44%—18% higher than the OECD average. The new price brings cigarette prices up to around 65% of the OECD average. The National Health Promotion Fund will receive 18.6% of the pack price to help fund cessation programs.

Pictorial health warnings and bans on advertising and promotion have also been introduced. Smoke free legislation has been expanded to include restaurants, cafes and bars under 100 sq metres unless they have a ventilated smoking booth, completely separate from food and drink serving areas. Smoke free legislation in 2012 had only applied to establishments larger than 100 sq metres. Penalties for violations are 100,000 won (US$92) for smokers and up to 5 million won (US$4600) for proprietors. Expectations that the measures would result in reduced smoking rates were reflected in the share price of KT&G Corp, the country's biggest cigarette producer, which fell by 21% at the end of December.

OBITUARIES: NIGEL GRAY & ANTHONY (TONY) HEDLEY

Read more at: http://blogs.bmj.com/tc/2015/01/12/obituaries-vale-tobacco-control-leaders-nigel-gray-and-anthony-tony-hedley/

Nigel Gray, 12 September 1928–20 December 2014

A decade after the WHO Framework Convention on Tobacco Control (FCTC) entered into force, it is hard to imagine tobacco advertising bans, confronting anti smoking advertisements and sustained global tobacco control policy action were once nothing more than radical ideas. Dr Nigel Gray, who died on 20 December 2014, was a pioneer in turning these ideas into reality, against fierce resistance from the powerful tobacco industry.

Dr Gray was pivotal in the campaign for the Victorian Tobacco Act 1987, groundbreaking legislation in the Australian state of Victoria which banned outdoor advertising of tobacco products and established the Victorian Health Promotion Foundation (now VicHealth) from hypothecated tobacco taxes. The VicHealth model has since been adopted elsewhere in Australia and internationally.

He was instrumental in introducing forceful anti smoking advertisements, health warnings and the establishment of behavioural research to inform tobacco control campaigns, as well as a generous mentor to many leading figures in international tobacco control and public health advocacy. According to former CEO of the Cancer Council Victoria, and past President of the UICC, Professor David Hill, “His commitment to research and action, his extraordinary mix of establishment persona and radical thinker and his ability to bring out the best in those working with him has created a blueprint for creating change that will be used for many decades to come.”

Internationally, Dr Gray was a leader in developing comprehensive policy approaches to tobacco control with the Union for International Cancer Control (UICC, of which he was president from 1990–1994), the World Health Organization (WHO) and other international health groups. In a tribute statement, WHO stated: “To those of us who worked closely with him, we saw a role model and mentor who was always humble, approachable, and never acted as if he was above anybody else even though he was light years ahead of us in his global vision.”

His legacy will continue to be felt in the global tobacco control movement, through the personal influence he had on many tobacco control leaders, as well as the two awards established in his name: the Nigel Gray medal (for outstanding leadership in tobacco control) and the Nigel Gray Distinguished Fellow in Cancer Prevention.

Anthony Johnson Hedley, 8 April 1941–19 December 2014

Professor Anthony (Tony) Hedley mentored, recruited and led for many years the team of researchers who laid the scientific foundation for tobacco control in Hong Kong, including epidemiology of harm from active and second hand smoke and research on tobacco promotion, taxation, economics, and smoking cessation.

After medical training and successive appointments in the UK, including as Professor of Public Health in Glasgow, Tony became Chair Professor of Community Medicine at Hong Kong University (HKU) in 1988. He recalled feeling that this was where he now wanted to be, no doubt appreciating the potential of a then relatively small department in a renowned medical school in such a unique, dynamic city state. From the outset, he was aware of Hong Kong's exemplar role and responsibility to the rest of the region.

In little more than 25 years the department of around half a dozen became the School of Public Health, with some 300 staff, working on a wide variety of research and teaching. Tony inspired and led pioneering work on air quality, a major public health issue in Hong Kong (he is commemorated in the Hedley Environmental Index) and health service research, in addition to tobacco-related research and advocacy. The most striking feature of his tobacco publications is their relevance to policy. A study of non-smoking catering workers, for example, clearly showed an inverse exposure-response relationship between lung function and workplace SHS levels quantified by both indoor fine particulate concentrations and urinary cotinine levels. It also demonstrated that a 30-month exemption of some premises from smoke-free legislation in 2006 was directly responsible for impairment of workers' health, providing powerful ammunition against pressure to relax the legislation.

While the Hong Kong Council on Smoking and Health, which Tony chaired from 1997 to 2002, handled ongoing public information work, Tony insisted that he and his colleagues were also directly involved in advocacy, educating government officials, politicians, the media and the public. An astute industry watcher, he was the first to blow the whistle on some of the most notorious industry scientific frauds regarding misinformation about SHS, revealed in part by detailed involvement in air quality research.

After official retirement in 2012, having accumulated numerous honours, Tony returned to the UK with his wife Sarah McGhee. Last December, HKU's Public Health Forum 2014 was entitled The Role of the Generalist in Public Health – a Tribute to Professor Anthony J Hedley. Already in failing health from a rare form of pancreatic cancer, he nevertheless made the return journey to Hong Kong thanks to help from friends and colleagues, attending and contributing to every session (http://pcp.sph.hku.hk/phf2014/index.php/photo-highlight). He said afterwards how fortunate he felt to receive such special recognition of his career. Hong Kong, Asia and the world are highly fortunate to have benefitted from Tony Hedley's life and work.

David Simpson

International Agency on Tobacco and Health

David.Simpson{at}ctsu.ox.ac.uk

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