Recent eLetters

Displaying 1-10 letters out of 370 published

  1. Re:No evidence that the tobacco industry evaded the FDA's ban on 'Light' cigarette descriptors

    NOT PEER REVIEWED This comment summarizes, but mischaracterizes the findings and conclusions of our study. Our analyses and interpretation are based strictly on the letter of the Family Smoking Prevention and Tobacco Control Act (FSPTCA) and its requirements, including Section 911(b)(2)(ii), which bans "the use of explicit or implicit descriptors that convey messages of reduced risk including 'light', 'mild' and 'low', or similar descriptions in a tobacco product, label, labeling or advertising". The findings demonstrated that manufacturers did not simply remove descriptors, to be in compliance with the law, but introduced new color- coded brand name descriptors which smokers were able to recognize and easily identify the formerly labeled "lights" brands. We did not examine the use of colors themselves, which may be protected by the First Amendment, but rather the use of color terms. The marketing materials examined make explicit the fact that the use of substituted color terms in brand names is similar to the dropped "descriptors, so that consumers will continue to recognize these brands as "lights". The National Cancer Institute previously found that filter ventilation has been used by manufacturers to delineate the misleading "lights" categories, which are now color-coded, and which conveyed messages of reduced risk resulting in increased initiation and reduced cessation. Our conclusions are stated in conservative terms that manufacturers appear to have evaded this critical element of the FSPTCA, which is intended to protect the public health.

    Conflict of Interest:

    None declared

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  2. Re:No evidence that the tobacco industry evaded the FDA's ban on 'Light' cigarette descriptors

    This comment summarizes, but mischaracterizes the findings and conclusions of our study. Our analyses and interpretation are based strictly on the letter of the Family Smoking Prevention and Tobacco Control Act (FSPTCA) and its requirements, including Section 911(b)(2)(ii), which bans "the use of explicit or implicit descriptors that convey messages of reduced risk including 'light', 'mild' and 'low', or similar descriptions in a tobacco product, label, labeling or advertising". The findings demonstrated that manufacturers did not simply remove descriptors, to be in compliance with the law, but introduced new color-coded brand name descriptors which smokers were able to recognize and easily identify the formerly labeled "lights" brands. We did not examine the use of colors themselves, which may be protected by the First Amendment, but rather the use of color terms. The marketing materials examined make explicit the fact that the use of substituted color terms in brand names is similar to the dropped "descriptors, so that consumers will continue to recognize these brands as "lights". The National Cancer Institute previously found that filter ventilation has been used by manufacturers to delineate the misleading "lights" categories, which are now color-coded, and which conveyed messages of reduced risk resulting in increased initiation and reduced cessation. Our conclusions are stated in conservative terms that manufacturers appear to have evaded this critical element of the FSPTCA, which is intended to protect the public health.

    Not peer reviewed.

    Conflict of Interest:

    None declared

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  3. Review of air quality, biological indicators and health effects of second-hand waterpipe smoke exposure - Letter

    NOT PEER REVIEWED Dear Editor,

    Research on waterpipe smoking, also called hookah, is still emerging, and research on second-hand hookah exposure is still in its nascent stages. However, after reading the review on the various effects of second -hand waterpipe smoke exposure by Kumar et al recently published in Tobacco Control1, we noted several major issues in its execution and have serious reservations about the potential of this review as a tool in the development of public health policy. First, the authors failed to synthesize all available research on the topic into their review, by utilizing only two electronic search databases. When a search was conducted in CINAHL, we found one more relevant article that could have been included in this review2. However, we are unable to judge as the authors don't present the inclusion criteria for the review. Furthermore, we found another systematic review on this topic and found that the amount of nicotine absorption resulting from daily hookah use was similar to that of daily cigarette use3. This is concerning because the authors did not include the older systematic review in the narrative nor did they derive information from it; consequently, calling into question the relevance of the current review. In addition, the authors were unclear regarding their methodology. They only provided a list of search terms and failed to specify any inclusion criteria, making it impossible for anyone to replicate their review. Second, the authors did not seem to have assessed the scientific quality of the included studies, negatively affecting the transparency of the review process. Thus, readers cannot properly assess its quality as a comprehensive review of the current body of literature or assess the validity of the findings that were included in the review. They also failed to assess publication bias, which would have been a relevant issue as they only included published studies. Given that a number of reporting guidelines for reviews have been produced, these issues are almost unjustifiable. Although the authors examined an important, often overlooked public health issue, their review suffered from major methodological flaws that could not be ignored. Unfortunately, the review's weaknesses prevent it from being a proper synthesis of the current body of research on the effects of second-hand exposure to hookah smoke and a useful tool for assisting decision-making in public health policy.

    REFERENCES 1 Kumar SR, Davies S, Weitzman M, Sherman S. A review of air quality, biological indicators and health effects of second-hand waterpipe smoke exposure. Tob Control. 2015; 24: i54-i59. doi: 10.1136/tobaccocontrol-2014 -052038 2 Aydin A, Kiter G, Durak H, Ucan ES, Kaya GC, Ceylan E. Water-pipe smoking effects on pulmonary permeability using technetium-99m DTPA inhalation scintigraphy. Ann Nucl Med. 2004; 18(4): 285-289. doi: 10.1007/BF02984465 3 Neergaard J, Singh P, Job J, Montgomery S. Waterpipe smoking and nicotine exposure: a review of the current evidence. Nicotine Tob Res. 2007; 9(10): 987-994. doi: 10.1080/14622200701591591

    Conflict of Interest:

    None declared

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  4. An update on smoking prevalence projections to 2025 and beyond in New Zealand


    Frederieke S. van der Deen and Nick Wilson (on behalf of the other authors; both from the University of Otago, Wellington, New Zealand)

    This electronic letter aims to give readers an update on the smoking prevalence projections to 2025 and beyond in New Zealand (NZ) that were provided in the paper by Ikeda et al. NZ is now one of four nations with an official smokefree goal (others are: Finland, Scotland, and Ireland). In NZ, this goal is generally interpreted as achieving a smoking prevalence under 5% by the year 2025.

    The modelling work by Ikeda et al aimed to explore the feasibility of achieving this goal under current annual trends in smoking uptake and cessation (ie, business-as-usual (BAU)). Smoking prevalence data from a regularly conducted NZ health-related survey between 2002 and 2011 were used to provide information on recent annual trends in smoking uptake and cessation as input for future BAU smoking prevalence projections. However, since this modelling work was first published (as an e-publication in 2013), smoking prevalence data from the 2013 Census has become available. A larger than expected fall in smoking rates in the general NZ adult population, but especially in Maori (indigenous population), was observed. It was therefore decided to update the future BAU smoking prevalence projections that were provided in the Ikeda et al paper by using smoking prevalence data from the 2013 Census.

    The updated future BAU projected smoking prevalence in 2025 was 8.3% and 6.4% for non-Maori (Ikeda et al: 10.7% and 8.8%), and 18.7% and 19.3% for Maori men and women, respectively (Ikeda et al: 30.0% and 37.3%). Although the updated projections are more favourable from a public health perspective (especially for Maori) than the previous modelling work, a smoking prevalence below 5% by 2025 is still not attained by any demographic group. Achieving the 2025 smokefree goal will most likely require implementation of more intense existing tobacco control strategies or potentially even entirely novel measures (eg, major changes in the tobacco retail environment as per the Tobacco Control themed supplement for March 2015 'The Pack and the Retail Environment').

    Updating the previously published smoking prevalence projections proved to be a feasible and relatively easy exercise. Projecting and regularly updating future BAU smoking prevalence projections with most up- to-date smoking prevalence data, in NZ and in other nations, may assist policy makers in planning how much more intense tobacco control measures may need to be to achieve smokefree goals. For more detail around the methods of updating the previous modelling work by Ikeda et al, we would refer readers to the recently published paper that describes this work [1].


    1. van der Deen FS, Ikeda T, Cobiac L, Wilson N, Blakely T (2014) Projecting future smoking prevalence to 2025 and beyond in New Zealand using smoking prevalence data from the 2013 census. N Z Med J 127 (1406): 71-79.

    Conflict of Interest:

    None declared

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  5. Tobacco industry peddling overestimates of illicit cigarettes to dampen tax increase


    We refer to the article, "Did the tobacco industry inflate estimates of illicit cigarette consumption in Asia? An empirical analysis" Chen J, et al. published in Tobacco Control on November 25, 2014 (Tob Control 2015;0:1-7) and concur with the important points raised in this article. While the article focuses on Hong Kong, other countries in South East Asia also faced a similar experience. The authors revealed that the tobacco industry-funded study on the illicit trade of cigarettes in Asia, "Asia-11 Illicit Tobacco Indicator 2012" by the International Tax and Investment Center (ITIC) and Oxford Economics (OE) inflated the extent of illicit consumption in Hong Kong by 133-337 percent. Similarly, other scholars have also questioned the methodology applied in this report. For example, Dr. Frank Chaloupka, Distinguished Professor of Economics at the University of Illinois at Chicago, criticized the reliability of the study's estimates in using an inconsistent approach and the lack of details about the empty pack surveys, the main source of data for the estimates. In June 2014, the South East Asia Tobacco Control Alliance (SEATCA) released a critique of the "Asia-11 Illicit Tobacco Indicator 2012" showing how its estimates are being used to rescind tobacco tax policies. As illustrated in Hong Kong's experience, the SEATCA critique revealed that the ITIC-OE report overestimated the total illegal consumption in other countries in South East Asia. In the case of Vietnam, it claimed that in 2012 about 103.3 billion cigarettes consumed in Vietnam were illegal, which amounted to 19.4% of total cigarette consumption. The estimate was based primarily on the data of a tobacco industry group, the Vietnam Tobacco Association (VTA), and the full details of the methodology were not disclosed. The report admitted that data were collected only in urban areas, but it failed to mention that 68.3% of the Vietnamese population live in rural areas. This means that the findings are not representative of the Vietnamese population and are very likely biased since illicit cigarettes consumption is concentrated in big cities and near borders.

    Unfortunately, as in Hong Kong, the glossy ITIC-OE study took its toll on tobacco tax policy in Vietnam. The Government of Vietnam considered the results of the study and opted for a less than ambitious tobacco tax rate increase. When the Ministry of Finance proposed a rather moderate tobacco tax roadmap in March 2014 (an increase from 65% to 75% in July 2015 and to 85% in January 2018), they noted that their decision was influenced by the illicit cigarette issue. The scope of illicit cigarettes consumption and the associated government revenue loss continued to be highlighted both in the press and during the policy debates until November 2014, when the National Assembly adopted an even weaker excise tax law: an increase to 70% in Jan 2016, and to 75% in 2019. Since these taxes are based on ex-factory price, and the tobacco industry is in full control of that price, the full impact on cigarette retail prices and tax revenue is likely to be minuscule. The average real retail cigarettes prices are expected to increase by less than 1% per year in the period from 2015 to 2020 (5.8% in 6 years), which, given the 5-6% annually per capita real income grows, is insufficient to prevent cigarette consumption from rising. In summary, the Asia-Illicit Tobacco Indicator 2012 report was as non- transparent in Hong Kong as it was in Vietnam and nine other countries covered by the report. It was used to undermine a pro-health tobacco tax policy supported both by public health advocates as well as the general public. We thank Tobacco Control for publishing the findings of Hong Kong colleagues, which successfully challenged the invalid evidence and arguments supported by the tobacco industry. We hope that other countries in Asia and elsewhere will follow Hong Kong's initiative and expose the tobacco industry's tactic to undermine pro-health tobacco tax policies that signatories to the WHO FCTC are committed to under Article 6 of the Convention.

    Thank you

    Sincerely, Son Dao , Hana Ross and Sophapan Ratanachena

    Conflict of Interest:

    None declared

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  6. Cook Islands data: some information and comment

    NOT PEER REVIEWED I commend the authors on a significant effort involved in conducting this rather insightful research.

    Having conducted qualitative research on FCTC implementation in the Pacific, I can provide comment in relation to the Cook Islands which may explain why MPOWER measures mentioned here did not achieve decreases in prevalence (at least in the figures obtained in this study).

    Firstly, the Cook Islands Tobacco Control Act was introduced in 2007 and accompanying regulations in 2008, and stakeholders informed me that compliance to these regulations was not strictly enforced until 2009 - hence their implementation on the ground may not have been felt until the latter period of or after this data was collected.

    Secondly, accurate, timely, comparative data on prevalence is extremely difficult to obtain in many small island nations such as those in the Pacific. I am unsure of the exact calculations behind the MPOWER reports and how these figures were extrapolated, but they are likely to be an estimation that is rather different to what other (national) studies suggest. The Cook Islands Census suggests a decrease in prevalence from 29% in 2006 to 20% in 2011. The Cook Islands GYTS (limited to those aged 13-15) suggests a decrease from 45% in 2003 to 35% in 2008, indicating the trend in prevalence is contrary to the statistics obtained in MPOWER.

    These potential limitations are duly noted in your study, but I thought this additional information would (a) be of interest and provide some context to these issues, and (b) serve to caution anyone who may suggest that MPOWER measures have not been effective in the Cook Islands (or elsewhere).

    Of course it would also be great to see further points of data collection beyond 2009, which would also give a better indication of trends over time.

    Conflict of Interest:

    None declared

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  7. Consider health-related outcomes when assessing the equity impacts of smoking ban policies

    NOT PEER REVIEWED We welcome the timely review published by Hill et al. [1], and agree that more research is needed to assess the equity impacts of tobacco control interventions. The results of the review indicated that "increases in tobacco price have a pro-equity effect on socioeconomic disparities in smoking", but that "evidence on the equity impact of other interventions was inconclusive [...]". The inconclusiveness of findings with regard to smoking ban policies may be partly due to date limitations for the database searches, which included evidence from January 2006 through November 2010. It may also be partly due to the assessment of equity in outcomes that related only to active smoking. Although a benefit of smoking ban policy implementation may be a reduction in active smoking, this outcome is dependent upon an individual's personal response to the intervention. However, the primary purpose for implementing comprehensive smoking ban policies is to reduce secondhand smoke exposure among the population through environmental change. It is therefore important to assess whether the successful implementation of smoking ban policies has pro-equity health effects.

    Our previous research indicated that the national smoking ban policy in the Republic of Ireland was associated with immediate reductions in all -cause and cause-specific cardiovascular, cerebrovascular, and respiratory mortality, and that these mortality reductions were primarily due to reductions in population exposure to secondhand smoke [2]. Our subsequent assessment of the socioeconomic differentials of these mortality reductions in the Republic of Ireland suggested that inequalities in smoking-related mortality were immediately reduced following smoking ban implementation [3]. Furthermore, given the higher rates of smoking-related mortality in the most deprived group, even equitable reductions across socioeconomic groups resulted in decreased inequalities in mortality [3].

    Partial smoking ban policies do not fully protect health [4], and are likely to yield negative equity effects as a result of policy exclusions for workplaces and hospitality venues located in more deprived areas [5]. In contrast, comprehensive smoking ban policies provide equal protection for all against secondhand smoke exposure. Indeed, previous studies have indicated that comprehensive smoking ban policies are effective public health interventions for reducing both exposure to secondhand smoke and other indoor air pollutants [6-11], the benefits of which are experienced by all employees and patrons of restaurants, bars, and other public places, regardless of individual socioeconomic group. Therefore, we wish to highlight that the evidence for pro-equity effects of comprehensive smoking ban policies may be more conclusive when additional health-related outcomes are considered.


    1. Hill S, Amos A, Clifford D, Platt S (2014) Impact of tobacco control interventions on socioeconomic inequalities in smoking: review of the evidence. Tob Control 23: e89-e97.

    2. Stallings-Smith S, Zeka A, Goodman P, Kabir Z, Clancy L (2013) Reductions in cardiovascular, cerebrovascular, and respiratory mortality following the national irish smoking ban: interrupted time-series analysis. PLoS One 8: e62063.

    3. Stallings-Smith S, Goodman P, Kabir Z, Clancy L, Zeka A (2014) Socioeconomic differentials in the immediate mortality effects of the national Irish smoking ban. PLoS One 9: e98617.

    4. Tan CE, Glantz SA (2012) Association between smoke-free legislation and hospitalizations for cardiac, cerebrovascular, and respiratory diseases: a meta-analysis. Circulation 126: 2177-2183.

    5. Lewis GH, Osborne DC, Crayford TJ, Brown AC (2006) Partial smoking ban would worsen health inequalities. Bmj 332: 362.

    6. Fong GT, Hyland A, Borland R, Hammond D, Hastings G, et al. (2006) Reductions in tobacco smoke pollution and increases in support for smoke- free public places following the implementation of comprehensive smoke- free workplace legislation in the Republic of Ireland: findings from the ITC Ireland/UK Survey. Tob Control 15 Suppl 3: iii51-58.

    7. Connolly GN, Carpenter CM, Travers MJ, Cummings KM, Hyland A, et al. (2009) How smoke-free laws improve air quality: a global study of Irish pubs. Nicotine Tob Res 11: 600-605.

    8. Goodman P, Agnew M, McCaffrey M, Paul G, Clancy L (2007) Effects of the Irish smoking ban on respiratory health of bar workers and air quality in Dublin pubs. Am J Respir Crit Care Med 175: 840-845.

    9. Mulcahy M, Evans DS, Hammond SK, Repace JL, Byrne M (2005) Secondhand smoke exposure and risk following the Irish smoking ban: an assessment of salivary cotinine concentrations in hotel workers and air nicotine levels in bars. Tob Control 14: 384-388.

    10. Valente P, Forastiere F, Bacosi A, Cattani G, Di Carlo S, et al. (2007) Exposure to fine and ultrafine particles from secondhand smoke in public places before and after the smoking ban, Italy 2005. Tob Control 16: 312-317.

    11. Eisner MD, Smith AK, Blanc PD (1998) Bartenders' respiratory health after establishment of smoke-free bars and taverns. JAMA 280: 1909- 1914.

    Conflict of Interest:

    None declared

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  8. Taxation may help, but perhaps new thinking is needed?

    NOT PEER REVIEWED Tobacco is an interesting consumer product. It is legal, toxic and dangerous. It kills people when used as intended. There is a global initiative to reduce use of this product opposed heavily by those profiting from it, tobacco industry stockowners. Industry has successfully blurred consumers, health professionals and policy makers over the years with false science, modulation of product and misleading marketing, product manipulation and new nicotine devices. In the 1970's the first anti- smoking movement was followed by the "light cigarette"- concept, in the 1990's when carcinogens entered public health discussion with environmental tobacco smoke, the industry came out with "less carcinogen" concept. Now the focus is finally moving to the pure addictive compound of tobacco, nicotine as we see the rise of "pure nicotine" -concept with electronic devices for inhaling nicotine in aerosols. So basically this industry has modified its very toxic product as we public health people have been responding to these new products, but really seeing, that old products remain available. In comparison with the petrol industry, which has faced similar challenges, for example high amount of lead needed in motors being environmental health threat. Reaction of the petrol industry was similar to the tobacco industry: developing new products, both cars and fuels. However, there is one distinct difference. These high-lead fuels are no longer on the market, but cigarettes are. So, if we have no courage to ban nicotine, why not follow the pattern of population protection strategies and ban the most harmful products first and then gradually move into nicotine free time. Taxing may help, but a gradual shift is worth thinking about, isn't it?

    Kristiina Patja, MD PhD, Finland

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  9. Working toward a more sophisticated conceptualization of health and trade

    In this rejoinder, we will address the recent response by Mary Assunta to our article, "Complexities at the intersection of tobacco control and trade liberalisation: evidence from Southeast Asia." To be sure, we believe that trade policy remains a very important issue for public health both in Southeast Asia and globally. Before addressing the specific concerns raised by the reader, it is worthwhile to restate the overarching argument, goals and approach in the original article. In brief, we argue and demonstrate empirically that over the last 15-20 years, sometimes considerable changes in trade policy have not systematically undermined tobacco control in Southeast Asia. Moreover, we also posit that penetration of the region by large international tobacco firms through investment is likely playing a much larger role in affecting public health policy. We do not discount trade entirely and largely agree with the reader that it has had some specific important effects, but these incidents do not undermine our general thesis.

    We completely concur with the reader's first concern that trade liberalization should be conceptualized as more than tariffs. This indeed was exactly our concern and largely motivated the research. In previous research and in discourse at international meetings, we observe too much emphasis on the more elementary aspects of liberalization and not enough on some of the areas that the reader, too, points out as important. The reader appears to have overlooked particularly both the abstract and the conclusion, which raise concerns with critical issues such as intellectual property rules and investor-state dispute settlement. We wish for the focus to be the right one, too, and it seems that we are on the same page for this goal.

    On the second major point, it appears that the reader is suggesting that transnational tobacco corporations use tariff reduction as a springboard into seeking further non-tariff liberalization. We would not dispute this contention, but we would also like to see much more compelling and rigorous evidence of this dynamic. The Philip Morris International (PMI) submission to the Transpacific Partnership (TPP) cited by the reader does not really make this connection sufficiently, in particular because the included passage is still really about tariffs or closely-related ancillary policies.

    The reader's third concern revolves around a purported dismissive treatment of the findings of Chaloupka and Laixuthai (1996), and Honjo and Kawachi (2000), particularly on the advertising dynamic. When we wrote, "Tobacco control policies were mostly nonexistent in these contexts too, so there was no obvious policy-based counter-force to the sudden changes in the tobacco marketplace" (which the reader cites almost verbatim in their critique), we were referring to the lack of these types of restrictions. We do not and would not dispute the important role that increased marketing played in re-shaping these contexts - it was undoubtedly an important part of the increase in imports and subsequent consumption. But our broader conceptual point is that the context in most countries now is different than it was in East Asia in the 1980s. First, most countries are already highly liberalized both in terms of trade and of investment. In most if not all of Southeast Asia, multinational tobacco firms are already firmly entrenched in terms of trade, investment and marketing (Vietnam is a partial exception because of tariff walls and the market constraints on multinational firms in their joint ventures with the state-owned tobacco enterprise). Thus, in many markets, firms have already been marketing for years and further liberalization in the classical sense is likely to make little difference strictly speaking. There is also good news in the contemporary era quite different than the 1980s in that some countries have strong marketing restrictions in place.

    The fourth concern in the response focuses on affordability. The reader's primary concern is that their data do not match ours. We re- checked our data and calculations, and remain confident in them. We are using the most up-to-date market data from proprietary sources such as Euromonitor and ERC (these services frequently update old data rendering older versions obsolete). While these sources are far from perfect, most in the tobacco control sub-field believe that they remain the best available for these types of data. It is critical to stress that we are using the cheapest brand (typically, a local brand, though not necessarily the most popular) for our calculations with the explicit logic that we want to explore barriers to consumer market entry (i.e. what is the least amount of money that it would take for someone to smoke regularly). Many other articles on tobacco affordability use prices of the most popular brand and/or an international brand such as Marlboro to calculate affordability. As we explain in the article, these choices are simply not theoretically suitable for our purposes. When we run cursory analyses with these other prices, we do note some of the differences that the reader points out; however, such differences are not relevant to our discussion.

    In response to the reader's concern about our interpretation of Figure 3, we appreciate the correction about Myanmar. The reader is correct that we erroneously indicated Myanmar when we meant, instead, to include Singapore in this list of countries with noticeable decline. As the reader rightly points out, Myanmar stayed about the same. In the process of writing the manuscript, we re-did this figure several times - ironically largely because we thought that the Singapore and Myanmar results were not accurate - with updated data (see the discussion above - sometimes we observed reversals in country-level trends after receiving market data updates) and unfortunately failed to update the text completely.

    We should also clarify the reader's misconception in Figure 3's interpretation about our apparent confusion around Indonesia and Vietnam. We actually split them apart in our narrative in order to draw attention to each of them. As we suggest, the broader contexts and dynamics in the two countries are quite different, but we wanted to highlight the similarity in outcome (increased consumption per capita) in two quite different scenarios. More broadly and importantly, the crux of the figure is the inconsistency across countries. Even our tiny descriptive error outlined in the paragraph above does not change this important characteristic in any way.

    In terms of the reader's very minor concern about our description of Vietnam as being "closed," please refer to Table 1, which discusses tariff rates. We do not purport to make a broader interpretation of openness (or "closedness" as the case is here) than the straightforward one that we clearly lay out. We also cite the joint venture activity that the reader seems to suggest as new and excluded information (see Table 4).

    We appreciate the reader's interesting discussion on affordability in Malaysia. We are very interested in the possibility that tobacco firms operating in Malaysia were able to keep prices down by importing cheaper leaf. However, the reader's discussion focuses on the delay of the prohibition of selling "kiddie" packs, conflating the actual causal relationships. Specific to the dynamic of tobacco leaf prices, it is also important to note that FAO price data suggest that these prices are increasingly global with limited cross-country variation (FAO STAT 2014). Moreover, leaf comprises only a surprisingly small part of the overall "cost" of a cigarette, so changes in leaf prices are unlikely to have enormous impact on affordability.

    In many ways, the complexities that the reader points out with the kiddie packs only strengthen our overall argument that the broader political economy of tobacco control is much more complex than changes in trade policies. That the tobacco industry is devious and employs many tactics only reinforces the important notion that the public health community has to keep the broader context in mind. Like the brief discussion above about one aspect of the complexities of measuring affordability (Which cigarette price should we use? Lowest? Most popular? Most commonly collected? Recognized international brand?), the dynamic that the reader describes raises another complexity - the definition of pack size for the calculation. Alas, this discussion about the vagaries of measurement in affordability - though very important - is beyond the purview of our brief study about trade liberalization.

    We thank the reader for pointing out our reversal of the dates for the investments in Malaysia and Indonesia. We appreciate the reader's keen sense of accuracy, but our main point remains unchanged: transnational tobacco firms are highly active investors in the region. Investment is almost certainly more important than trade liberalization in terms of affecting the dynamics that we discuss, including affordability and relevant policies.

    In the Philippines-Thailand dispute at the World Trade Organization (WTO), the reader appears to confuse the basic tenets of Article 5.3 of the World Health Organization's (WHO) Framework Convention on Tobacco Control (FCTC). One of the key goals of Article 5.3 is to ensure that the tobacco industry is excluded from direct participation in making tobacco control policy. The article also presses for transparency when governments deal with the tobacco industry more generally, but the FCTC does not ask governments to cease all relationships with the tobacco industry. Elsewhere, the authors and colleagues have examined in considerable depth (e.g. Chavez et al 2014; Drope et al 2014) the lack of irrefutable evidence that the tobacco industry did anything that is not permitted - in the FCTC or otherwise - to get the Philippines government to pursue the dispute at the WTO. That the industry helped to pay some of the legal costs (incidentally, we failed to obtain confirmation of this scenario in our on-the-ground research) is neither illegal nor unusual. Firms in many other industries in other countries have behaved similarly at the WTO and it is not expressly prohibited. Perhaps the reader believes that pursuing such a case is tantamount to an incentive, which Article 5.3 does identify as not permissible, but the case for such a dynamic remains to be made. While we personally feel that governments should not pursue these cases on behalf of the tobacco industry, it is clearly in trade ministries' mandates to act to protect their constituents, of which the tobacco industry is one.

    Rather than relying on anecdotal and often unverified media accounts, we formally interviewed dozens of the key official and unofficial players involved in this and related dynamics in the Philippines and we did not find any "smoking gun" evidence of corrupt behavior. What the public health community considers "bad" or undesirable behavior does not necessarily qualify as corruption. Finally, we never suggested that civil society had to produce the evidence - as researchers, we should not care from where the evidence comes. We should, however, care deeply about the quality of the evidence, and be able to gather it and evaluate its validity and reliability with considerable objectivity.

    Finally, in regard to the referenced Joint Memorandum Circular (JMC), it is worth noting that there are internal struggles within the Philippines as the domestic tobacco control legislation (RA 9211) and the FCTC remain in some or even considerable tension. Many government departments point out that the FCTC has never been properly domesticated with enabling legislation as the political and legal structure in the Philippines requires (see Magallona 2013 for a discussion of how this works). So, in the eyes of many, the JMC does not have the force of law (see Lencucha et al, forthcoming).

    In regard to the concern about regulatory chill, we do not purport at any point that regulatory chill does not exist; rather, the actual dynamic that we examine in the article is that chill is a very difficult phenomenon to identify unequivocally. To take the reader's example of New Zealand, our colleagues (officials in governments) have explained to us that there is limited political support for plain packaging beyond Minister Turia and some in the Maori Party and the Green Party. In brief, our sources suggest not only that the minister lacks support from many other key actors (including particularly in the minority government's coalition-leading National Party), but that blaming regulatory uncertainty ("chill") is a thinly-veiled and convenient excuse to avoid pushing the legislation that a number of officials simply do not want. The scenario in New Zealand seems likely to be precisely the dynamic that we are discussing in this article. Incidentally, the dynamic that we examine may be just as or even more problematic to the public health community than basic "chill." We cannot speak to what is happening in this area in Malaysia as it was not part of our research - perhaps it is regulatory chill in the truest sense - but it has to be demonstrated rigorously. From personal perspectives, we are quite concerned about regulatory chill, and particularly for low- and middle-income countries that rightfully fear costly litigation, but as we state clearly and for which we make a compelling case, as a scholarly community we simply do not yet understand well the actual dynamics of regulatory chill. Clearly, it is a much needed avenue of future research.

    After the discussion of regulatory chill, the reader reiterates one of our key conclusions - which we do not seek to prove empirically - that investment almost certainly plays a significant role in affecting the tobacco control outcomes examined in this research. Our discussion is fully congruent with the reader's observation that investment in countries like the Philippines and Indonesia is surely having a significant effect on tobacco control and related efforts. Again, we are advocating not only more systematic research on trade policies' effects on tobacco control, but more broadly, to expand research focus to the dynamics around investment in the tobacco sector.

    Finally, on the issue of a tobacco carve-out in the TPP, we would suggest that typical dynamics of the international system - well developed theoretically and substantiated empirically - suggest that the prospects for a Malaysia-style proposal are likely to be rather dim (for a broad set of relevant theoretical discussions, see, for example, Baldwin 1993). First, international agreements are deeply affected by state power and in the TPP scenario, Malaysia is a relatively weak actor, while several of the other much stronger states have stated an explicit preference for an alternative arrangement (the US) or have intimated that a carve-out is not likely to be acceptable (Japan). Second, and intrinsically related to the first dynamic, in an international trade negotiation like the TPP, all parties must agree, so the prospect of total agreement on a complete tobacco carve-out is currently not strong. It is possible that other countries will use the Malaysia proposal as a foil in order to find some middle ground, which might still work out well for public health. It is also possible that because the proposal is so unpopular with some key actors that negotiating parties might choose ultimately to exclude it entirely from the negotiation (much the same way that trade has thus far been excluded from the Framework Convention on Tobacco Control). Finally, we highly doubt that Malaysia will withdraw from the TPP if it does not get its way on tobacco, which suggests strongly that it is probably not the most important issue on its trade ministry's negotiating agenda.

    The dynamics above also apply to the re-negotiation of the thousands of existing agreements that the reader suggests is attainable with some hard work. Unfortunately, both theory and recent experience suggest a genuine struggle to negotiate trade agreements more broadly. For example, the WTO's Doha round was essentially stuck for more than a dozen years and the supposed breakthrough in 2013 was eventually about the relatively non- controversial area of trade facilitation and ignored the many other pressing issues that have contributed to the long gridlock (WTO 2013). It is also important to consider that many international economic agreements do not come up for renegotiation naturally or will not expire for many years. Any enthusiasm for re-negotiation may eventually be tempered by the sheer size of the endeavor. We do agree, however, that a TPP that enshrines health in a way that protects and promotes tobacco control and public health is a crucial set of goals for the global community.

    It is also important to consider that the idea of a tobacco carve-out is mostly untested. We fear that it will not be the panacea that many advocates suggest. Tobacco exclusion may even be detrimental in some circumstances by perpetuating market structures that serve strong pro- tobacco interests - for example, by preserving the market share of politically-strong tobacco firms (this dynamic is somewhat similar to a scenario where under certain conditions marketing restrictions can also serve to preserve market share for powerful incumbent firms). In two recent major international economic agreements, the Pacific Island Countries Trade Agreement (PICTA) and the South Africa-European Union Trade, Development and Cooperation Agreement (TDCA), it was a major transnational tobacco firm operating in favorable domestic conditions pushing governments for a tobacco exclusion policy (personal communication with a South African treasury official).

    A final and more crucial point is that the international trading system has rules that seek to tackle the complexities of making policies across sectors (e.g. public health and economic policies). As Drope and Lencucha (2014) discuss, the seminal Thailand - Cigarettes case at the General Agreement on Tariffs and Trade (GATT) actually laid a reasonable foundation for how to make good public health policy that integrates successfully with world trade rules and goals (see for example, paragraphs 77-78 from GATT 1990). In some ways, the slightly bizarre U.S.-Clove Cigarettes case also generated some similar proactive discussion from the WTO wherein the panel was explicit about permitting the banning of tobacco additives as long as it was not discriminatory (see McGrady 2011 for a discussion). The panel reports demonstrate these dynamics clearly (see WTO 2011, 2012).

    As a broader community - i.e. beyond tobacco control - we suggest that we need to develop a world trading system that can accommodate many other important health-related issues such as unhealthy foods, alcohol and access to medicines (to name only a few) that sit squarely at the nexus of public health and economic policymaking. Re-working or tweaking some of the rules of the world trading system might be a good place to start. But we are unwilling to throw out all of the existing rules and are suggesting that they have even sometimes served to try to integrate health and trade meaningfully in ways that do not necessarily undermine health (see the examples in the paragraph above). Another recent case worthy of consideration is the Philippines - Distilled Spirits dispute at the WTO, which ultimately was the primary catalyst for the recent successful tobacco excise tax reform in the Philippines (see Chavez et al 2014; Drope et al 2014). We underscore in our article, and reinforce in this rejoinder, that the international economic system is complex, but it is not without opportunities to promote public health.

    In regard to the quote from a Philippine trade official about a lack of support for a tobacco carve- out in ASEAN, it is important to reiterate context. First, the official was speaking about the AFTA, not the TPP, which is to what the reader is referring. Second, returning to the original interview transcript, the official also stated that no influential trade official that s/he knew of was in favor of a carve-out. Whether the Malaysian proponents prove to be sufficiently influential to include a tobacco exclusion in AFTA still remains to be seen. Finally, this was a key informant interview of an influential actor in one country in this regional agreement - these are not our views necessarily and we do not at all purport that these are the only views. Moreover, we do not suggest anywhere in the research that the tobacco carve-out discussion is only occurring in Southeast Asia. We set up our case study justification for Southeast Asia by acknowledging the regional discussion, but this does not suggest that there is no discussion of carve-outs elsewhere in the global community.

    In sum, the key argument in our article that trade policy has not systematically undermined tobacco control in Southeast Asia remains strongly supported. Moreover, the reader appears to concur with us that investment is a key variable in the political economy of tobacco control in the region. In many ways, it appears that we and the reader are simply coming from entirely different epistemological and methodological traditions. We are seeking to identify and explain broader patterns across time and space (in this case, countries in Southeast Asia) and learn from them, where in contrast the reader seeks to focus in large part on the exceptions to the patterns that we are underscoring. We acknowledge the complementarity of research that seeks an approach focused on important exceptions and identify some effective recent articles in this research vein (see endnotes 24 and 34-38), but it is important to recognize that each approach offers distinct utility. In an important research topic and moral cause - such as the health-trade nexus - we need to take great care not to prematurely dismiss others' rigorous and transparent work, and exploring a wealth of different approaches can only be good.


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  10. A tobacco carve-out is the way for the future

    I would like to respond to this paper by Drope J and Chavez JJ whose analysis focuses on cigarettes, not tobacco leaf production and trade, and seeks to question the "conventional wisdom" that "trade liberalization naturally leads to lower prices for tobacco products, increased consumption and decreased levels of regulation." The authors use theoretically guided empirical research to demonstrate there is little cause for concern on the negative impact of trade liberalization on tobacco control policies. They have focused on Southeast Asia as an "ideal most likely case" because the region has experienced recent trade liberalization regionally and multilaterally, and because the "tobacco control proponents from the region continue to voice loud concern about the issue suggesting that it is perceived as a genuine threat," and conclude their proposal to carve out tobacco from trade agreements is "sub -optimal". The authors omitted and overlooked some crucial evidence, details, and developments on tobacco, trade and tobacco control on the ground which I will address in this response. There are also some errors which need to be corrected.

    Firstly, trade liberalization through new free trade agreements are not just about eliminating tariffs, but includes addressing "non-tariff barriers" such as national legislation, product standards, services, investment, intellectual property rights, government procurement and environment which may be just as important or even more important than tariffs for regional economic integration. In the Trans-Pacific Partnership (TPP) to which the authors refer, only 5 chapters of the total 29 chapters actually deal with traditional trade issues while the rest are about dismantling non-tariff barriers to trade. There is the real threat that corporations are using trade agreements to get special benefits that they would find much more difficult to get through the standard legislative process. Trade agreements' impacts on tobacco control, among others, include challenging clean indoor air rules, controls on sale and distribution of tobacco products, cigarette content regulation and bans on tobacco advertising and promotions. It is in this context that the impact of trade liberalization on tobacco control should be seen and not limited to the narrow scope of tariffs alone.

    Secondly, transnational tobacco companies (TTC) themselves have traditionally supported the lowering of tariff barriers to tobacco both historically and continue to support it even now for the added value it brings them to influence non-tariff barriers. Philip Morris International (PMI), for example, in its submission to the TPP said, "The negotiations should be comprehensive and lead to the complete elimination of all tariffs on all goods. There are tools - such as longer phase-out periods and temporary special safeguards - that can be used to mitigate the impact on products deemed "sensitive" by participating national governments."

    Trade liberalisation - The authors are rather dismissive of previous studies on trade liberalisation and tobacco control in East Asia such as papers by Honjo and Kawachi, and Chaloupka and Laixuthai as being limited to a narrow set of market conditions since they involved state-owned tobacco monopolies, where tobacco control policies were mostly non-existent and there was no obvious policy based counter-force to the sudden changes in the tobacco marketplace. The Honjo and Kawachi study actually provides clear evidence that the opening of Japanese markets to the TTC "stalled a decline in smoking prevalence" and the contributing factors to opening of the market included removal of non-trade barriers such as the actual elimination of restrictions on advertising and promotion on tobacco products, which saw an increase of marketing and promotion by these companies. This is also consistent with strategies revealed in the internal industry documents which suggest that besides tariffs elimination the American companies also wanted: "(b) access to all retail outlets. (c) Eliminate advertising limitations. (d) Allow us to do effective market research and product test marketing."

    Affordability - The data of the authors show the RIP (relative income price) of only Brunei, Cambodia and Philippines have reduced. However according to the data of the Southeast Asia Tobacco Control Alliance, the RIP of cigarettes also decreased for Lao, Indonesia and Vietnam, besides Philippines and Cambodia, meaning that overall, cigarettes became cheaper across many countries in the ASEAN region following the introduction of AFTA.

    The authors refer to Figure 3 to illustrate changes in consumption per capita, demonstrating mixed results, though not precisely in the same pattern they observe with affordability. They point out the most pronounced declines have occurred in Malaysia, Myanmar and Cambodia, and that the only clear upward trend is in Indonesia. However this description does not match data in Figure 3 accordingly. For example Figure 3 shows Myanmar's per capita consumption has remained unchanged (around 200 sticks), while the decline in Singapore has been reversed as of 2006. After identifying Indonesia as the only county with a "clear upward trend" the authors go on to say Vietnam is the only ASEAN country with a "strong upward trend".

    They describe Vietnam as the only country that continues to have a "closed tobacco sector." It is unclear what exactly this means as the state owned Vinataba has joint-venture agreements with both British American Tobacco (BAT) and PMI.

    Change in affordability - The authors make considerable reference to Malaysia, indicating it has experienced the greatest change with substantial imports, prices, policies and the tobacco trade. The authors point out when the government increased specific excise taxes from RM28 per kilogram to RM220 per 1000 sticks by 2010, cigarettes became less affordable. What has been omitted is the tobacco industry gained by importing cheaper leaves and mitigated the cigarette price increases by successfully lobbying to delay the implementation of regulations banning kiddie packs (less than 20 sticks) which was passed in 2004 but only implemented in 2010. The tobacco industry kept cigarettes affordable through the sale of kiddie packs. Contrary to the graph in Figure 2 showing cigarettes becoming "dramatically less affordable" in Malaysia, another study conducted by the International Tobacco Control Project, found affordability to have increased by 1.9% over the four years (2005 - 2009). These findings show that tobacco taxes and prices did not increase at a rate high enough to offset income growth, and cigarettes became more affordable to consumers.

    Using small packs to keep cigarettes affordable particularly to the young is further confirmed in the internal tobacco industry documents on Malaysia. PMI for example, in their internal documents say, "...As the total outlay for a pack of 20's became too prohibitive for our younger adult smokers we should consider smaller packings. Currently we plan to reduce the price of our 14's pack from M$2.40 to M$2.20. Should this move not yield the desired results, we will launch a 10's and 7's packing in this strong growth segment."

    An error that needs correction is about the PMI factory in Malaysia. According to the authors, "PMI opened a new US$40 million plant in Malaysia in 2005, while purchasing remaining shares in Sampoerna Indonesia, which they had partly purchased in 1995." In actual fact PMI opened its manufacturing facility in Malaysia in 1995, which was its first plant in Asia. Ten years later in 2005 PMI purchased PT HM Sampoerna in Indonesia.

    The authors refer to Thailand and Vietnam as being the "only countries with a WHO MFN rate of 60% or greater" - this is a typographical error for WTO as the WHO does not offer any MFN status to any countries.

    In February 2008, the Philippines government filed a complaint to the WTO, claiming a bias against imported cigarette brands in Thailand. The authors claim that while tobacco control civil society groups in the Philippines have expressed concern that the case is a violation of FCTC Article 5.3 because tobacco firms in the Philippines, particularly Philip Morris-Fortune Tobacco, might have exerted inappropriate pressure on the Philippine government to pursue the case, the groups have not produced unequivocal evidence of an Article 5.3 violation. Firstly, the authors have failed to recognise that there are many newspaper reports indicating that the case was filed by the Philippines government on behalf of Philip Morris which cannot be ignored and warrant an investigation to ascertain if there is indeed an Article 5.3 violation. Secondly, the authors have not clarified why it is civil society's responsibility to provide the evidence and not the government's to facilitate an investigation when in the Philippines there is a mechanism to implement Article 5.3 through the Joint Memorandum Circular (JMC) 2010- 01 of the Civil Service Commission and Department of Health.

    Regulatory chill - On regulatory chill the authors claim it is difficult to identify such incidents definitively because there can be "multiple explanations for governments' policy choices". It appears the authors may be ignorant of tobacco control activities on the ground. In the case of New Zealand which has started legislative process on plain packaging of tobacco and seen first reading in Parliament, the legislators won't pass it into law "until legal action in Australia has been settled". BAT and Imperial Tobacco, which sued the Australian government, have threatened to take similar action if plain packaging is introduced in New Zealand. The New Zealand Prime Minister said they decided not to take a chance in breaking any trade rule, that it would be too expensive for New Zealand to face a legal challenge from tobacco companies. Similarly the Malaysian Health Minister has said Malaysia will watch the legal outcome in Australia on plain packaging.

    The authors are dismissive about regulatory chill in the context of the developing nations being studied. If it is too expensive for New Zealand to fight such legal challenges, the reality is even more stark for low and middle income countries which simply cannot afford protracted legal battles. This is illustrated in Uruguay's experience of being unable to afford legal costs in meeting PMI's challenge and seeking assistance from US philanthropies. The challenge launched in 2010 is still ongoing. Uruguay's President has now made an appeal to the US President for assistance in stopping PMI from annulling their tobacco control legislation.

    The authors' conclusion that the very mixed results across key aspects of the trade and tobacco nexus suggest that there is no clear-cut link between trade liberalisation and a decline in tobacco control and/or an increase in tobacco consumption in Southeast Asia must be seen in the context of the errors and omissions pointed out above. While the authors need not address all aspects, such as ways in which the TTC benefited from AFTA beyond tariff reductions and conducted efforts to thwart tobacco control measures, they could have mentioned them in the limitations. Indonesia and the Philippines are the two countries where the TTC have consolidated their presence by acquiring or merging with local companies. BAT which exited the Philippines has since returned in 2012 and has benefited from the recent tax hikes through what it calls a more "level playing field".

    Tobacco carve-out - The authors claim that simply arguing trade liberalisation is bad for tobacco control and that excluding the tobacco sector from economic agreements is the solution is a "suboptimal" strategy. The authors have attributed this call for a tobacco carve-out to "tobacco control proponents from the region" as in a proposal limited to a specialised group. The authors' doubts about the political viability of excluding tobacco from such economic agreements have already been contradicted by the Malaysian government's formal tabling of just such a provision in the TPPA in August 2013. Malaysia's proposal received wide media coverage. The complete carve-out proposal is based on the recognition that tobacco products are uniquely harmful and the global consensus that nations must act to reduce tobacco use, according to the WHO Framework Convention on Tobacco Control (FCTC).

    In reality the call for a tobacco carve-out is not confined to just "tobacco control proponents from the region" but is echoed by public health advocates, medical groups, academics and lawyers from New Zealand, Australia, the US and Peru. Additionally in January 2014 the Attorneys General of 45 states in the US urged the US Trade Representative to exclude tobacco from the TPP entirely, stressing that "there is no policy justification for including tobacco products in agreements that are intended to promote and expand trade and investment generally." Needless to say these Attorneys General are not from Southeast Asia.

    Malaysia's proposal to the TPP was submitted by officials from the Ministry of International Trade and reiterated by the Minister contradicting the authors' claim that there is a "gap between trade and health practitioners". This also lays bare the authors' quote from a Filipino high-ranking trade official that "no key trade or finance officials in ASEAN countries are openly supportive of this proposal (tobacco exclusion)".

    The authors say tobacco exclusion may even be problematic and advise tobacco control proponents to counteract aggressive marketing by the tobacco industry by being more prudent and pursuing FCTC-compliant bans on tobacco advertising, promotion and sponsorship. If the authors simply recognized the fact that Australia plain packaging was challenged despite "being prudent" then they would realize that their recommendation for prudence has no basis and is not an alternative to the so-called suboptimal solution. The Australian plain pack example also clearly explains the regulatory chill effect in other countries that the authors dismiss.

    In questioning the political viability of tobacco exclusions, the authors focus on the challenges of the broader task of affecting trade negotiations successfully but not on the benefits. Of course, nothing in tobacco control was achieved easily, more so in trade agreements. They have all been hard fought battles and we continue to fight them in developing countries.

    The authors refer to the "additional burdens of returning to hundreds of previously negotiated economic agreements" but they should know that the practical solution is when these agreement expire and/or come up for renewals, to address tobacco then. Hence it is vital to secure a tobacco exclusion in the TPP, touted to be the 21st Century free trade agreement to provide the standard for future agreements.


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