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

USA: ALTRIA, CYCLING'S LATEST DRUG STAIN

Altria is boasting on its website that it is a founding partner of the Richmond Union Cycliste Internationale (UCI) Road World Championships, held in September 2015. The sponsorship is highlighted in an upbeat video that makes no mention at all of the company's main line of business.

Pascal Fernandez, senior vice president, Consumer and Marketplace Insights at Altria Client Services talks about growing up in France watching Tour de France “I did bike racing myself and I'm…super excited to think we're going to be hosting this event, we're going to have all these champions coming into town, showing a different side of Richmond…”

Exactly what is meant by showing a different side of Richmond is not clear – perhaps Mr Fernandez means the contrast of an elite international sporting event hosted by a town which is home to a multinational company where profits can be counted in the number of lives cut short. Certainly the vision of cyclists at the peak of aerobic fitness is a striking contrast to the misery of the last years of many smokers, tethered to an oxygen machine or disfigured by cancer surgery.

EUROPE: TRANSPARENCY BLACKED OUT ON TOBACCO

The European Commission has been criticised by NGOs and Members of the European Parliament (MEPs) for failing to adhere to its transparency obligations as a party to the World Health Organization Framework Convention on Tobacco Control (FCTC). The criticisms arise from a Freedom of Information (FOI) request lodged by NGO Corporate Europe Observatory (CEO) in March 2015 for documents related to the Transatlantic Trade and Investment Partnership (TTIP), a proposed free trade agreement between the USA and the European Union, expected to be the largest trade agreement in history.

The FOI request was about meetings between EC Secretary General Catherine Day's team and the tobacco industry, and was filed to determine if EU trade negotiators were pushing for investor to state dispute settlement (ISDS) provisions in trade agreements. ISDS provisions have been used by the tobacco industry to mount legal challenges to national tobacco control provisions in countries such as Uruguay and Australia.

Following a series of delays, the last of the documents were finally released in August, but were so heavily redacted as to be virtually meaningless. Names of Commission staff, content, dates and even page numbers were blacked out. The European Commission's justification for the redactions has been contradictory: Commission deputy chief spokesperson Alexander Winterstein stated the redactions were to guard commercially sensitive information and adhere to European Union law, and denied that the documents had anything to do with the TTIP.

However, secretary general Day defended the redactions on the basis that the public interest in transparency “does neither outweigh the public interest in protecting the Commission's international relations and decision-making processes” and stated that because the documents contain elements related to the Commission's negotiating position with regards to tobacco in bilateral negotiations for a free trade agreement with the USA and Japan, they cannot be released as they would reveal the Commission's negotiating positions and tactical considerations.

Ms Day's statements appear to suggest that the tobacco industry has had privileged access to information, a concern raised by Irish MEP Nessa Childers, who has called on Ms Day to clear up any confusion and asked the Commission to confirm that the documents had nothing to do with the TTIP.

Despite years of controversy over tobacco industry lobbying leading up to the adoption of the European Union's revised Tobacco Products Directive, the Commission's latest actions suggest that it continues to treat the tobacco industry in the same way as any other business.

CEO filed a complaint with European Ombudsman Emily O'Reilly, who found that – with the exception of the DG Health – the Commission was not sufficiently transparent about its meetings with the tobacco industry. She called for all meetings and their minutes to be proactively published online.

INDIA: SMOKELESS TOBACCO BAN SHOWS EARLY SUCCESS

‘Bans don't work’ is a common response to measures to restrict or outlaw tobacco supply. Libertarians decry such measures as excessive ‘nanny state’ intervention; others point to the USA experience of alcohol prohibition in the 1930s, often held up as a failed experiment. However, India is proving that prohibition can have a place in public health. Gutka, an industrially manufactured smokeless tobacco product has now been banned in the majority of the country, with encouraging results.

Spurred by attractive packaging in single-dose plastic packs affordably priced at 2–3 cents/pack, and widespread marketing targeted at children and adolescents, the gutka market has rapidly expanded in the last decade to be worth more than US$8 billion. The growth of the industry has caused havoc with public health, especially oral health. According to the Global Adult Tobacco Survey (GATS) India 2009–10, around 13% of males and 3% of females used gutka in India. Among young people aged 15–24, smokeless tobacco use was 23% for males, and 8% for females. Use of smokeless tobacco usage is a key risk factor for cancer (mainly oral, oesophageal, and pancreatic), stroke, ischaemic heart disease, type 2 diabetes, adverse reproductive and developmental effects such as stillbirth, preterm birth and low birth weight.

The legal basis for the gutka ban was the Food Standards and Safety Act notified in 2011, section 2.3.4 of which specified that “Product not to contain any substance that may be injurious to health: tobacco and nicotine shall not be used as ingredients in any food product”. At the direction of the Supreme Court, the Ministry of Health and Family Welfare (MoHFW) constituted a high level Expert Committee to collate the evidence on harmful effects of smokeless tobacco and areca nut. In February 2011 the Ministry submitted this report, commonly called National Institute of Health and Family Welfare (NIHFW) Report to the Supreme Court. Several Civil Society NGOs urged the highest court to ban the manufacture and sale of all products found to be injurious to health by the NIHFW health report.

Momentum for the gutka ban, however, came from tobacco victims themselves; survivors of cancers of mouth and throat, widows and families of tobacco victims. Known as ‘Voice of Tobacco Victims’ (VoTV), the campaign featured patients and their family members, supported by their treating oncologists and public health researchers, telling their stories of initiation and addiction to gutka and consequences of disease, financial ruin and agony.

Started in 2011, the target audience for the VoTV was top policy makers, bureaucrats, social influencers, media and politicians. The appeal from patients made direct emotional connections; politicians and bureaucrats made promises and media gave prominent coverage to stories. The VoTV doctors and staff provided scientific evidence, made the advocacy demands very specific, and followed up with bureaucrats and politicians until the objective was met. Ultimately, the first gutka ban was declared by the state of Madhya Pradesh on 1st April 2012. Thereafter, state after state notified the ban. For some states who refused to implement bans, public interest litigations were filed and High Court judgments forced them to declare the gutka ban. By the end 2012, 14 of India's 29 states had notified the ban and in April 2013, the Supreme Court directed all states to comply.

The extent of enforcement of the ban varies a great deal across states, but there have been some common findings. The first major impact assessment report came in 2014, from a study conducted by the Johns Hopkins University Bloomberg School of Public Health and the World Health Organization. Surveys were conducted with 1,001 current and former gutka users and 458 tobacco product retailers in seven states (Assam, Bihar, Gujarat, Karnataka, Madhya Pradesh, Maharashtra and Orissa) and Delhi. Interestingly, 90% of respondents desired that the government should ban the manufacturing, sale and distribution of other forms of smokeless tobacco.

According to the study, there was virtually no retail outlet where pre-packaged gutka was on display. Ninety two percent of respondents supported the ban and 99% agreed that bans are good for the health of India's youth. Of the respondents who continue to use illegal pre-packaged gutka, half reported they consume less since the bans. 80% believed that the ban would motivate them to quit, and nearly half of attempted to do so. Of the respondents that quit since the bans, a substantial proportion in each state (from 41–88%) reported that they “quit using gutka because of the ban”. The study was a rapid survey in 7 states, rather than a nationally representative survey.

Following the bans, however, most gutka manufacturers started selling two packets: one the same mixture but without tobacco; and a small packet containing just tobacco, often given free. Users were urged to combine and mix the ingredients of two packets to create their own gutka. This innovation adversely affected the purpose and consequent impact of the ban and was possible due to weak enforcement of the law. However, 11 states took action by banning the sale of processed and packaged smokeless tobacco and flavored areca nut products.

A concern for public health policy makers and researchers was to determine if gutka chewers switched to smoking following the ban. Studies have consistently shown that there is almost no switch over to smoking. In fact, the whole campaign for the gutka ban, aided by other tobacco control measures, seems to have impacted sales of all forms of tobacco. According to the Index of Industrial Production (IIP) data, output of tobacco declined by 12.1% in March 2015 from a year ago.

The Euromonitor report on Smokeless Tobacco in India, published in December 2014, revealed that up to 2010, volume of sales as well as the value of sales of smokeless tobacco were increasing, were more or less stagnant in 2011, and by 2013, there was an 84% decline in volume and 82% decline in value of sales compared to the peak in 2010. Further, compared to 2012–13 figures Euromonitor predicted the decline in sale volume to be 85% and value to be 80%. Euromonitor attributed this decline to the gutka ban. Also, for the first time in the history of the cigarette industry in India, the volume of sales have started declining.

These findings assume even greater importance when considered along with the overall economic impact of tobacco use in India. According to a report by MOHFW, health care losses due to treatment of tobacco-related illnesses were US$16.5 billion [Rs.1.04 trillion] in 2011. In comparison, in 2013–14, the Government's earnings from tobacco taxes were US$2.83 billion [Rs.17,800 crores].

The findings here reaffirm the fact that investment in tobacco control policies represents a win-win for government, public health and the people and families of tobacco users or potential users. India's experience shows that prohibition of products may be a credible tobacco control option in certain situations. In this case, the product was primarily manufactured in one country and cross border supplies could be reasonably controlled. In addition, the ban appears to have led to denormalisation of gutka. By declaring the product illegal, the consequential massive earned media in the country convinced the public (90%+ approval ratings) that banning this product was good for the public‘s health. This also countered the massive brand equity makers had built up around their gutka brands—the “stench” of a banned product led to erosion of the brand values. The ban has effectively disrupted supply, especially reducing access to children.

This is an edited version of a story originally published on the Tobacco Control website. The full article, including links to references and additional author credits, can be accessed at http://blogs.bmj.com/tc/2015/08/27/can-prohibition-work-the-case-of-indias-smokeless-tobacco-ban/

Pankaj Chaturvedi

Tata Memorial Hospital, Mumbai, India

chaturvedi.pankaj{at}gmail.com

Sanjay Seth

Healis Sekhsaria Institute for Public Health

INDIA: KERALA BECOMES FIRST TOBACCO AD-FREE STATE

Kerala has become the first state in India to become tobacco advertisement free. This major milestone for public health in the country represents strong government commitment, a favourable policy framework, accountability, and engagement by various departments to achieve robust enforcement.

The first step was successfully abolishing tobacco advertisements at the points-of-sale – an effective and easy option used to create a sustained reminder about these dangerously addictive products. According to the Global Adult Tobacco Survey 2009–10, 44.2%, 70.9% and 72.3% of Kerala adults above 15 had seen advertisements on cigarettes, bidis and smokeless tobacco respectively.

Kerala is home to 34 million people. The state's Chief Minister, Mr Oommen Chandy has said, “Public health has been and will be our priority. Over the last four years, we have undertaken far-reaching tobacco demand and supply reduction measures such as a ban on pan masala and gutkha containing tobacco or nicotine, an increase in tobacco product taxes, and successful completion of the drive to remove advertisements at the points-of-sale in the state”.

The Public Health wing of the Kerala Health Services Department spearheaded the extensive campaign that resulted in removal of tobacco advertisements from 95.3% of points-of-sale over an 18-month period across 14 districts of the state. Kerala Police joined forces in this mega-effort.

Dr AS Pradeep Kumar, a medical doctor with a PhD in tobacco control and then Additional Director of Health Services (Public Health) who coordinated this effort, said a three-phase activity plan was developed with District Medical Officers at the core. “Sensitisation programmes were conducted with emphasis on Section 5 of COTPA for district officers at the state capital”. (COTPA is India's tobacco control law; Section 5 bans all forms of direct or indirect tobacco product advertising). “District officers in turn trained and authorised personnel attached to Primary Health Centres,” he added.

The districts were given the freedom to customise according to their local needs. “This, in turn, raised the level of commitments and ownership taking. At the state level, we supported the districts by framing guidelines, monitoring and advising course corrections,” said Dr Kumar.

The process that started during World No Tobacco Day 2013 saw both integrated and intense drives that effectively pooled the services of health personnel from district to primary health centre level. Over 130,000 points-of-sale were inspected in drives held in two phases, from June to December 2013, and in January 2014, and notices issued to erring outlets. Notices mandated that advertisement boards, stickers, or posters be removed within 7–10 days. Wherever ads were not removed, they were confiscated. Police assisted as needed. Regular monitoring continued until October 2014.

An evaluation study by an external agency reported an overall compliance of 95.3%–98.5% of points-of-sale free of any advertisement boards and 96.7% of points-of-sale free from stickers and print advertisements. The evaluation team, with 90 trained volunteers, observed 22,344 points-of-sale across the state. Kerala Voluntary Health Services, a civil society organisation with a nearly four-decade-long experience in research and field implementation in Kerala conducted the evaluation study. The team looked out for hoardings, posters, stickers, display of cost, display of tobacco products or any other promotional material at points-of-sale.

In November 2014, Kerala was declared the first tobacco ad-free state in India. Sustainability of the achievement is being ensured by integrating it with ongoing inspections by the Health Department in the state.

This story is also published on the Tobacco Control website and can be accessed at http://blogs.bmj.com/tc/2015/09/04/kerala-indias-first-tobacco-ad-free-state/

Rema Sundar

Tobacco Free Kerala, India

remasundar2015{at}gmail.com

INDONESIA: KRETEK CIGARETTES PROPOSED AS UNIQUE ‘CULTURAL HERITAGE’

Indonesia, one of a handful of nations to have not signed the FCTC, has been a notable laggard in tobacco control. In recent months, the country has started to take some small steps towards addressing the enormous toll of smoking with the introduction of pictorial health warnings (although enforcement has been weak).

However, in an ominous sign, in September the English-language Jakarta Globe reported that a proposal has been put forward by a committee of the Indonesian parliament to include kretek (clove) cigarettes as an item of cultural heritage under the country's Cultural Heritage Law. The proposal would elevate kretek cigarettes to the same status as important archaeological sites and traditional arts, and oblige the government to support the kretek industry.

The proposal was criticised by Vice President Jusuf Kalla and other government officials, including the Education Minister and Health Ministry. The House of Representatives Legislation Committee deputy chair defended the proposal on the basis that kretek needed special rules to protect against them “being stolen by other nations”. As the Education Minister retorted: “…not every traditional custom must be developed and preserved”.

Given the heavy burden smoking imposes on the Indonesian people, facilitated by poor knowledge of the dangers of smoking and advertising long banned in many other countries, kretek would be one aspect of Indonesia's cultural heritage that would best be abandoned. To do otherwise is to risk international ridicule at a time when most nations are working to end the tobacco epidemic.

WORLD: TOBACCO RECOGNISED IN SUSTAINABLE DEVELOPMENT GOALS

On 25 September, the 2030 Agenda for Sustainable Development was adopted by world leaders. Aimed at achieving sustainable development for all, the Agenda consists of 17 Sustainable Development Goals (SDGs), which mark a turning point for addressing non-communicable disease, and recognise tobacco control as a strategy to address sustainable development and improve health. The FCTC is one of four means of implementation for SDG 3 (Health), and tobacco taxation is referenced in the Addis Ababa Action Agenda - a framework to catalyse investment in the SDGs. A six year campaign was led by the Non-Communicable Disease Alliance to include NCDs as a global health priority.

Absurd juxtaposition: this image of an elite cycling event sponsored by Altria is strikingly at odds with the reality of lives ruined by smoking, as shown by the lower image taken from a UK anti-smoking ad which tells a heartbreakingly common story of a man with lung and throat cancer 10 days before his death.

A 14-page redacted letter from the tobacco industry as redacted by the European Commission in response to an FOI request by Corporate Europe Observatory. Source: http://corporateeurope.org/international-trade/2015/08/black-out-tobaccos-access-eu-trade-talks-eerie-indication-ttip-threat

A screenshot from the powerful Voice of Tobacco Victims campaign.

A range of international NGOs campaigned for NCDs and tobacco to be included in the Sustainable Development Goals. This graphic by unfairtobacco.org highlights the links between tobacco and poverty.

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