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Worldwide news and comment
  1. Marita Hefler
  1. Menzies School of Health Research, Northern Territory, Australia
  1. Correspondence to Ms. Marita Hefler; marita.hefler{at}menzies.edu.au

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The theme for this year’s World No Tobacco Day, held on 31 May was ‘Tobacco – a threat to development’; a potent reminder that the negative impacts of tobacco include affect not only health, but also economic growth and the environment. With over a billion deaths forecast this century if current trends continue, reducing tobacco use remains an urgent priority, particularly for populous low and middle income countries with a high proportion of young people, where it is estimated 80% of the world’s tobacco users live.

Despite the harms of its products, the tobacco industry continues to obstruct, delay and attempt to dilute the introduction of evidence-based measures which meet countries’ obligations under the WHO Framework Convention on Tobacco Control (FCTC). As a lower middle-income country and the world’s second largest consumer of tobacco (including bidis and smokeless tobacco) India is a prime example of the frontline against the tobacco epidemic. In this issue, we look back at delays and obstruction encountered in India on the more than decade-long journey to introducing 85% graphic health warnings.

We also note two recent developments which undermine the tobacco industry’s strategies to lobby through third parties and attempt to position their companies as both normal and socially responsible. The International Tax and Investment Centre (ITIC), which has been described as ‘perhaps big tobacco’s most perfect front group’, has cut its long-standing ties with the industry. Meanwhile, a partnership between Philip Morris International (PMI) and the Danish Institute for Human Rights has come to an abrupt end, with a recommendation that PMI should immediately get out of the tobacco business.

Denmark/world: Philip Morris’ blunt human rights advice

In December 2016, Philip Morris (PMI) and the Danish Institute for Human Rights (DIHR) announced a collaboration “to develop a human rights implementation plan across PMI’s value chain”. The collaboration, which started in September 2016, was planned to continue until August 2017. The intention was for DIHR to examine PMI’s policies, procedures and practices with a human rights lens and make recommendations for the company to ensure its approach was in accordance with the UN Guiding Principles on Business and Human Rights (UNGPs).

The DIHR is a quasi-state body, and the partnership had been criticised by the global public health community, who had asked DIHR to end the partnership in line with Article 5.3 of the FCTC and its human rights obligations.

On 4 May, DIHR announced on its website that it had ended the engagement with PMI with a blunt and simple message: PMI cannot continue to be in the tobacco business and be aligned with the UNGPs.

As DIHR explained, “According to the UNGPs companies should avoid causing or contributing to adverse impacts on human rights. Where such impacts occur, companies should immediately cease the actions that cause or contribute to the impacts. Tobacco is deeply harmful to human health, and there can be no doubt that the production and marketing of tobacco is irreconcilable with the human right to health. For the tobacco industry, the UNGPs therefore require the cessation of the production and marketing of tobacco’.

The response from Philip Morris noted “Acknowledging and acting on the societal harm caused by our products is central to our human rights commitment and to our vision for a smoke-free future to replace cigarettes with smoke-free products’. Notably, a direct response to the advice that it needs to get out of the tobacco business altogether was missing. In shifting the focus to its declared ‘vision for a smoke-free future’, PMI also sidestepped the issue of a timeframe for achieving this vision.

In its response to the DIHR announcement, PMI also stated that it will report on actions to implement a more systematic rights-based approach in its annual Communications on Progress to the UN Global Compact. Perhaps that is when it will finally announce the date by which it will ‘stop selling cigarettes’, as it has been mentioning on its website and in recent press releases.

PMI, and the tobacco industry generally, are now on notice: it is not possible to be a good corporate citizen upholding human rights when your business includes tobacco. In a joint press release, the NGOs Unfairtobacco and ASH USA also noted that stopping the sale of tobacco is consistent with the UN Sustainable Development Goals (SDGs), the adoption of which Philip Morris has publicly welcomed.

World: International Tax & Investment Center ends tobacco ties

In recent years, the International Tax and Investment Centre, which describes itself as an ‘independent, non-profit research and educational institution’, has attracted scrutiny for its work to help the tobacco industry gain a ‘seat at the policy table’. Its activities prompted the WHO to urge all governments to follow a non-engagement policy with ITIC. The World Bank also withdrew from a tax conference co-hosted by ITIC in India in 2015 following concerns raised by the public health community. ITIC has been sponsored by tobacco companies, and had staff members on its board from British American Tobacco, Philip Morris International, Japan Tobacco International and Imperial Tobacco Limited (for more background, see coverage in the January 2016 edition at http://tobaccocontrol.bmj.com/content/25/1/5).

The ongoing controversy over ITIC’s tobacco ties has now prompted the group to cut its links with the tobacco industry. In May, it announced that it would no longer accept sponsorship contributions from the tobacco industry, and all tobacco company representatives had been asked to resign from its board. In a sign of just how tainted the tobacco industry is, ITIC president Daniel Witt told the Financial Times “The anti-tobacco campaigns became too great a distraction from ITIC’s mission, and this was a necessary step to safeguard ITIC’s reputation and ensure its long-term effectiveness’.

The move has been welcomed by health groups. ASH UK chief executive Deborah Arnott stated ‘this is a major blow to Big Tobacco’s modus operandi of covert lobbying under neutral-sounding cover’. Alex Cobham, chief executive of the Tax Justice Network highlighted the importance of the move for curtailing tobacco industry influence in emerging markets: ‘We’ve eliminated what is big tobacco’s main lobbying channel in many lower-income countries’.

However, the Southeast Asia Tobacco Control Alliance (SEATCA) has called on ITIC to go further than simply addressing the reputational issue, and take steps to address the content and substance of ITIC’s documents and their recommendations to governments, which have served the tobacco industry’s interests. To do this, SEATCA has outlined several steps for ITIC to demonstrate it has effectively cut tobacco industry ties. These include: making the new policy of disengagement from the tobacco industry public on the ITIC website, embracing the WHO FCTC Article six guidelines as its benchmark on tobacco tax, and taking corrective action to withdraw all PMI-sponsored reports from circulation to ensure that they do not misguide governments.

India: the long road to 85% pictorial tobacco pack warnings

Smokers carry packs and see cigarette packages on an average 15 times a day and 5500 times a year, making pictorial pack warnings the most cost effective measure for raising awareness about the harms of tobacco among users. More than 40 countries in the world have implemented pictorial pack warnings, with many more moving in that direction. The size of the graphic health warning determines its impact; larger warnings are the most effective.

Two of the pictorial tobacco health warnings which were implemented in May 2009 after extensive delays. The images replaced larger and more graphic warnings which had originally been planned for implementation in February 2007. Research subsequently found that these images were ineffective and misunderstood as butterfly and/or astrology signs.

Two of the images used on 85% pack warnings which were finally introduced in India in April 2016, a decade after graphic health warnings were first announced.

As in many other countries, the journey to implementation of effective graphic warnings in India has faced significant challenges. The tobacco control law, The Cigarettes and Other Tobacco Products Act (COTPA), enacted by the Indian Parliament in 2003, required all tobacco products to have a health warning which should be legible, prominent and conspicuous in colour and size. India subsequently ratified the Framework Convention on Tobacco Control (FCTC) in 2004, which mandated that health warnings be implemented within 3 years, that is, 2007. FCTC guidelines recommend pictorial health warnings as the most effective. Despite these policy and legislative frameworks, there were significant delays in announcing stronger warnings. Even after they were announced, implementation was delayed and the legislation diluted due to tobacco industry interference.

In July 2006, pictorial health warnings for tobacco products were announced for the first time. The image included a skull and crossbones and images of the adverse health impacts of tobacco. In line with best practice, images were required to be changed every 12 months. The warning was to cover 50% of the surface on both sides of the tobacco packets, and come into force from February 2007.

Following industry opposition, strong lobbying and a media campaign against the warnings, in January 2007, a Group of Ministers (GoM) comprised of Union Ministers was constituted to provide recommendations to Cabinet about pictorial pack warning implementation. A series of meetings were held, which resulted in several delays to implementation. In September 2007, the skull and crossbones were removed, and weaker images were announced, to be implemented from December 2007. These were then delayed further to March 2008.

In March 2008, the GoM decided to replace both sets of the previously notified pictures with smaller and less effective warnings. These new rules superseding the original 2006 ruling and were notified with a new set of pictorial warnings to be implemented from November 2008.

In November 2008, implementation of the pictorial warnings was stalled again, with a new implementation date of 31 May 2009. On third May 2009 a new Government order was issued reducing the pack warnings to only 40% on the front panel of the principal display area of the tobacco product packages. These were finally implemented from 31 st May 2009. However, studies showed that these were ineffective, with people mistaking the warnings for a butterfly and/or astrology signs.

Less than one year later, in March 2010, new stronger pack warnings were notified and were to be implemented by June 2010. In April 2010, the Indian Ministry of Health & Family Welfare (MoHFW), agreed with research which demonstrated that the existing warnings featuring lungs and scorpion were ineffective. In May 2010, MoHFW announced that the stronger warnings would be implemented from 1 st December 2010. However, in August 2010, the MoHFW cited ‘technical issues’ for further delay in implementation. This time a civil society organisation, Health for Millions, filed a petition in the Supreme Court challenging the May 2010 notification.

Under pressure in the Supreme Court, the MoHFW proposed an amendment to the rules which included four new pictorial warnings to be used on tobacco and bidi packages and four new pictorial warnings for smokeless packages. Implementation of these rules began on December 1, 2011 and allowed tobacco companies to choose any one picture out of each set of four images for smoked and smokeless tobacco products.

Following continued tobacco industry opposition, the MoHFW proposed a new round of warnings that were to be used from April 1, 2013. A set of new pictorial warnings were developed for smoked tobacco products and a separate set for smokeless tobacco products. These were implemented in April 2013 under significant civil society pressure to prevent further delays.

In October 2014, the Ministry proposed larger warnings to cover 85% of the front and back of the pack. The larger warnings were initially scheduled to come into effect April 1, 2015 but–perhaps unsurprisingly-the deadline was extended indefinitely because of objections by a Parliamentary Committee on Subordinate Legislation. A great deal of civil society activity and many legal battles followed before the 85% warnings were finally implemented in April 2016.

The 85% pictorial warnings on both sides of tobacco packs are now in force. This measure has elevated India from 136th to third rank globally for the size of its picture warnings. However, it has been a long road, with over a decade of delay tactics and successful lobbying from the tobacco industry - a lost decade in which millions of Indians have died early because of their tobacco use, and millions have started or continued to use tobacco products which will rob them of a healthy future.

This article and related links and are published on our website at http://blogs.bmj.com/tc/

Ashima Sarin

Voice of Tobacco Victims & Amity Institute of Public Health, India

sarina@healis.org

Rajiv Janardhanan

Amity Institute of Public Health, India

UK: last-ditch attempt to undermine plain packs

Smokefree Murihiku ran activities at the ILT stadium in Invercargill to celebrate World No Tobacco Day (known as World Smokefree Day in New Zealand). The event focused on smoke free environments and cars as reflected on the car’s licence plate. In December 2016, the NZ Parliament Health Committee recommended that the government ban smoking in cars carrying children under 18 years. In March 2017, the government declined to follow the recommendation, despite a 2012 survey which found that 23% of 14-15 year olds reported exposure to smoking in a vehicle within the last week. On current assumptions, it is estimated that 90,000 young people under 18 are exposed to smoking in cars at least once per week. Photo credit: Smokefree Murihiku.

As the phase-in period for plain packs came to an end in the United Kingdom, reports emerged of Philip Morris distributing 10-cigarette tin containers printed with Marlboro branding. With the new cigarette regulations also outlawing 10 cigarette pack sizes (particularly popular with children), the tins sidestepped plain packaging, size restrictions and larger health warnings.

News of the tins appeared at the same time that Philip Morris announced the launch of a 7 day smoker ‘conversion’ programme, billed as a ‘major step to ‘smoke-future’. According to PMI, the programme is aimed at switching the first 100,000 UK smokers to its heat-not-burn product IQOS. It is backed by hundreds of support staff, an e-commerce website, and a network of new IQOS retail outlets as well as partnerships with other retailers.

Details about what the ‘conversion’ programme would consist of, and the training of support staff were absent from the announcement. Long-time tobacco industry watchers would note that a 7 day programme, dedicated website and retail network would certainly provide intensive engagement with sales staff, and an opportunity for ongoing awareness of PMI brands – just as significantly tighter regulations for conventional tobacco products come into full force.

While the announcement was also careful to state that the programme is targeted at smokers who are unable to quit, it is hard to imagine non-smokers will be turned away. With over £2.3 invested in scientific research and development, PMI will be presumably be looking to keep shareholders happy by growing this new market, not simply converting existing smokers from one product category to another.

What if smokers don’t want to quit conventional cigarettes, or new IQOS users want something stronger? Well, PMI has that product category well covered. As it says on their website it “is the world’s leading international tobacco company… six of the world’s top international 15 brands, spanning more than 180 markets are ours, including Marlboro, the world’s number one…for those who choose to continue to smoke, we will continue to offer them the best quality products.’

New Zealand: former PM calls for urgent action on smokefree 2025

Former New Zealand Prime Minister and former Administrator of the United Nations Development Programme (UNDP) Helen Clark has been appointed as a patron of ASH New Zealand–Action for Smoke-Free 2025.

On her appointment, announced immediately prior to World No Tobacco Day, Ms Clarke highlighted that progress for New Zealand to achieve its Smoke Free 2025 goal is too slow and will take 30 years. She called on politicians to show courage and leadership, noting that ‘the challenge is bigger than any one government’s term, or any one election’.

In line with the WNTD theme of tobacco and development, she reflected on her experience as the UNDP administrator had given her insight into how low income countries are targeted by the tobacco industry, and of related problems such as child labour and poverty within the tobacco industry. She also observed the importance of New Zealand’s leadership on global tobacco control–although the impact of tobacco on development is also felt in New Zealand. As in other countries with minority Indigenous populations, it is Maori people who are disproportionately affected by tobacco; Ms Clarke noted that one in four Maori women are dying from tobacco-related causes.

In calling for collective political action, she said “Every day in implementing policy, every time ideology beats science, every time the tobacco industry threatens litigation and we get scared – these reactions all result in more lives lost to tobacco… If our politicians don’t make this a priority, don’t act on the evidence and don’t stand together against the tobacco industry, we will be mourning lives lost to tobacco for another generation.’

World no tobacco day 2017

World No Tobacco Day was marked by a range of new policy announcements, reports and studies. From New Zealand, where a policy for the defence forces to become fully smoke-free by 2020 was launched, to Indonesia - where the National Commission on Tobacco Control urged the government to finally sign the FCTC, and Austria, where a 30 year study was released showing that only a 1% increase in taxes reduces tobacco consumption by 0.5%. Full coverage is on our website at http://blogs.bmj.com/tc/2017/05/31/world-no-tobacco-day-2017-how-different-countries-are-celebrating/.

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Footnotes

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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