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To western observers interested in tobacco control policy, Japan is a fascinating anomaly. Despite its extraordinary achievements in manufacturing and technology, coupled with its high levels of education and research, and an economy that until a recent blip, probably only temporary, has been a world leader, its smoking rates have been sky high, with subsequent disease levels to match. In many ways, to a westerner it is rather like a Germany of the East.
Two decades ago, Japan had the highest male smoking prevalence of any industrialised country, at around 80%, but an almost negligible prevalence among women. Then came the invasion of American tobacco companies led by the US Trade Representative in 1985. Along with Thailand, Taiwan, and South Korea, Japan rolled over and modern tobacco promotion began. Until then, the Japanese tobacco monopoly (ironically, in view of Japan’s high incidence of hypertension and stroke, it was called the Japan Tobacco and Salt Public Corporation) had been supplying a large and eager male market but had desisted from what must have so attracted the foreign invaders—the almost totally non-smoking female half of the population. A wind of change was in any case blowing through Japanese society, with increasing numbers of young women not only having significant disposable incomes—it is still quite common for young working women to live with their parents until marriage, usually later than their western counterparts—but traditionally strict attitudes to women’s behaviour were softening. What better way for tobacco companies to recruit them than by somehow exploiting this new mood of liberation? Just as in many emerging, fast growing developing countries, the potential to nearly double the market by recruiting women to smoking must have been the western tobacco companies’ dream come true.
Within a decade, smoking rates among young Japanese women had shot up, well on the way to those of young western women. Then, in 1999, Japan Tobacco (JT), as it was now called, bought the non-US business of RJ Reynolds. This catapulted the company, still two thirds owned by the state, into the same league as the newly merged BAT and Rothmans, making it second equal in size after Philip Morris. Added to the existing high smoking rates—though men were beginning to quit—the potential for serious tobacco control was dealt a severe blow, as the government was now swung sharply to the side of tobacco.
Japan therefore suffers more than its fair share of that unsatisfactory dichotomy common to many governments, whereby the ministry of finance, unaware or unconvinced that tobacco tax rises can increase revenue while lowering consumption, is by far the most powerful ministry, and resists any policy that might reduce consumption. In fact, whatever the finance ministry might want to do, as majority owner of JT it is legally bound to defend its huge investment. Conversely the ministry of health, always low in any country’s cabinet pecking order, became relatively lower still, condemned to a weary cycle of trying to develop policies that might actually reduce future disease levels, then watering them down progressively as the ministry of finance, no doubt advised by its charges at JT, ensures that nothing that could seriously affect it is ever implemented. Most official health initiatives, despite some valiant attempts, end up with a noticeably soft “advisory” flavour. The only hope of health prevailing over tobacco is when the government sells its majority shareholding in JT, something it is pledged to do but has put off until the share price, hit by the recent recession, makes a significant recovery.
Advertising and promotion has continued to flourish. From the early onslaught by Philip Morris, including its notorious exploitation of the 1980s Japanese cult for James Bond movies, in which the company’s Lark brand was contracted into a movie playing to sell-out young audiences, tobacco promotion has steadily developed, nowadays with full participation by JT, into something much more recognisable to western eyes. Uncannily familiar, in fact—due to Japan’s unique, strong cultural traditions, ads for products that may be seen as controversial or embarrassing tend to use western models. For example, billboard ads for women’s underwear, a fairly essential commodity in Japan as elsewhere, show western women rather than their Japanese sisters. Tobacco ads targeted to women follow the same line—about the only sign of any reservation by society about the plethora of seductive ads clearly designed to appeal to girls and young women.
Other forms of promotions to women are more subtle, if more devious. Last year, Salem ran a promotional package of two packs of Salem cigarettes, an unmistakably girlie, pocket sized pink powder compact, and a booklet of special offers. It showed a wide range of household goods, of typically fine and attractive Japanese design, available to those young women lucky enough to buy the pack. Not surprisingly, some of the same young schoolgirls who can be seen experimenting with make-up as they dawdle back home after school can now be seen smoking in the street, too.
Perhaps the greatest give-away of the government’s enslavement to tobacco is its approach to the Framework Convention on Tobacco Control. The ministry representing Japan in the negotiations has been the ministry of finance—the health ministry had mere observer status on a committee assembled to inform the government’s negotiating position. True, one member of the committee was a scientist, but he had a track record of research on addiction for JT. The chairman himself was a cardiologist, with no known tobacco connection, but unfortunately, Japanese tradition demands that the independence of the chair is observed scrupulously, so that those chairing committees cannot make known their views. Other committee members included a stockbroker, representatives of tobacco retailers and farmers, and a steel company executive.
Whatever some officials in the health ministry might wish to do, then, taking a strong lead in tobacco control is simply not possible while the government remains the majority shareholder in JT. Non-governmental organisations (NGOs), however, are becoming more active. Japan has always had some active NGOs working on tobacco, as well as a number of individual activists, but while the larger medical charities have tended in the past to stick to safer topics such as cessation and youth education programmes, recent years have seen signs of change. The Japan Cancer Society, for example, which in the past mainly concerned itself with screening, is now moving towards primary prevention. Half a dozen organisations, including cancer and heart charities, foundations for maternal and child health, and the anti-tuberculosis association, have been working together within an NGO council for tobacco control.
More recently, the Japan Medical Association (JMA) and the Japan Nursing Association have both become much more active on tobacco. Last year, for example, the JMA translated Doctors and tobacco, the action guide for medical associations and their members, and used it to hold well attended seminars in several population centres, including one at the headquarters of the JMA in Tokyo. It was encouraging to find that much progress has been made in recent years by modest yet highly active leaders in the national and regional medical associations. They have surveyed doctors’ smoking rates and attitudes, as well as making medical association premises smoke-free. Doctors’ smoking rates, while high for such an advanced society, are now coming down (from a 1999 level of around 27% for men, 7% for women), and there is increasing interest in tobacco control.
Japan has about 260 000 doctors, of whom around 60% belong to the JMA. Public health, one of the natural pools of leadership on tobacco control found in other countries, has almost no system for qualification in Japan, even though it is a recognised medical specialty. So far there is only one school of public health, part of Kyoto University, which opened two years ago. There is a growing demand to get smoking cessation counselling included among services for which doctors are reimbursed, with all the related problems of quality control and assurance of the delivery of an effective service. As in other countries, many clinicians routinely try to get their patients to quit, and some feel that their colleagues should do the same whether or not they are reimbursed. Meanwhile, in the business world, employers are increasingly realising the benefits of getting smoking employees to quit, and making workplaces smoke-free.
In Japan’s often smoky public places, too, there is progress, even if the most publicised smoking ban recently, on certain busy Tokyo streets, was motivated by people, especially children, being burned by the glowing cigarette butts of careless smokers rushing by. Seeing that the epidemiology of passive smoking and lung cancer began life in Japan, with the late Professor Takeshi Hirayama’s 1981 pioneering study, a more sustained, science based public places campaign might have been expected. However, the politeness for which Japan is so deservedly famous is, for tobacco control, a two edge sword. On the one hand, it means that when there are no smoking areas, in public transport and certain other (though too few) public places, they tend to be scrupulously observed; on the other hand, in terms of ordinary members of the public asserting their right to breathe smoke-free air, Japanese people must be among the most reticent in the world, at the opposite end of the spectrum from the non-smokers of the USA whose constant and assertive demands have proved so potent.
There are signs that coalitions of anti-smoking groups will coalesce into a more powerful force, and there is a growing demand for training. There is likely to be a record Japanese contingent in Helsinki this summer. We must hope that Japan’s economy allows the government to sell its JT shares, and begin the serious business of hands-on, health driven, comprehensive tobacco control.