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- BAT, British American Tobacco
- CDC, Centers for Disease Control and Prevention
- DFID, ????????????
- EPA, Environmental Protection Agency
- EU, European Union
- FCTC, Framework Convention on Tobacco Control
- NGOs, non-governmental organisations
- NIH, National Institutes of Health, NRT, nicotine replacement therapy
- SRNT, Society for Research on Nicotine and Tobacco
- WHO, World Health Organization
Keynote address at the Society for Research on Nicotine and Tobacco annual meeting, Prague, 21 March 2005
This year has begun well for tobacco control. One hundred and ninety two countries, all members of the World Health Organization, have solemnly pledged to rid the world of the death and disease trail caused by tobacco. Sixty countries have ratified the Framework Convention on Tobacco Control (FCTC) and thus given us an instrument with which we can systematically tackle all aspects of tobacco control including agriculture and finance, trade and commerce, education and health.
Together with the then director general of the WHO, Dr Gro Harlem Brundtland, I had the privilege of laying the foundations upon which this public health edifice was built. When we started our work in July 1998, few believed we would succeed. The tobacco industry watched us with bated breath and tried to thwart our work at every step.
SIGNIFICANT POLICY CHANGES
Last week, I asked friends on GLOBALink around the world what they considered to be the most exciting and significant policy changes at country or local level to advance tobacco control over the last six months. GLOBALink includes tobacco control advocates and researchers who share knowledge and ideas through a closed website. Their response was fast—the first came within minutes of my query. They told stories of activism and progress, courage and leadership in an area of public health that no longer makes headlines. Every success story means fewer lives lost.
Let me share some of the stories with you.
From the world’s largest democracy, India, we heard about a total ban on tobacco advertising, ban on smoking in public places, and the latest Indian budget raised tobacco taxes. From Canada, a world leader in tobacco control and one of the earliest supporters of the FCTC, we heard that their supreme court voted down the tobacco industry’s challenge to their Saskatchewan‘s law banning point of sale advertisement of cigarettes in retail outlets paving the way for Manitoba, and in time, other provinces to move towards such a ban. Our friends in the UK brought news of implementation of point of sale regulation limiting promotion to a single A5 ad.
In France a regulatory change involving a new indication for smoking reduction with nicotine reduction therapy is in the works, and Venezuela will see new and bolder warnings in a month. Our Thai colleagues, second to none when it comes to tobacco control, cited bigger and according to the Bangkok Post, “scarier” picture pack warnings that take up 50% of the upper portion of both sides of the faces of cigarette packs. With this, Thailand becomes the fourth country to use such warnings after Canada, Brazil, and Singapore. And more countries, including those in the European Union (EU), are planning to introduce similar warnings soon.
For the last three months all pubs and restaurants in New Zealand have been smoke-free, without exception, and I have just been to Ireland where I enjoyed Guinness in smoke-free pub on St Patrick’s Day—an experience quite unthinkable just a few years ago.
During this conference we will hear about the extraordinary widespread impact of the ban on total consumption and quitting rates in Ireland. The data will show that the Irish have responded as the people of California and New York City have. They are smoking less in all settings and even smokers now support the ban. I have no doubt that the New Zealand ban will lead to a similar response. And so will Norway, Australia, Canada, and other countries and communities who are introducing comprehensive bans on smoking in public places.
Professor Stan Glantz has been right all along. Smoke-free policies work. They reduce the prevalence of smokers and increase support for tobacco control. That is why industry has always feared them, as they do Stan himself. Smoke-free public places should be the norm, not a privilege, and we should be pushing aggressively to achieve this.
We should expose those calling for partition as representing the voice of the tobacco industry. We should insist that health authorities provide better access to cessation support through quit lines and nicotine replacement, simultaneous with expanding smoke-free public places. Pharmaceutical companies selling cessation products should support local and national non-governmental organisations to develop and implement smoke-free policies.
In addition to local action from all over the world, we also have real evidence of reduced tobacco prevalence from many parts of the world. Latest data from the Philippines suggest that from 2000 to 2003, tobacco use and exposure to secondhand smoke in pubic places declined significantly among students aged 13–15 years. Students were more likely to support bans on smoking in public places. This occurred as major changes in tobacco control policies were being debated, and some implemented.
We have a lot to celebrate, but this is not the time to ease the pressure on governments because the FCTC is the floor. It holds within it the promise of a stronger treaty, and more than a handful of countries around the world have escalated their domestic tobacco control commitments above the international norm.
This is not the time to lose track of one simple fact—a billion people will die of tobacco this century, 10 times more than the estimates of the 20th century. We have to thank Richard Peto and Alan Lopez for reminding us that prospects for a levelling off of the global epidemic are decades away.
BEWARE OF COMPLACENCY
Unfortunately, governments and international agencies run the risk of becoming complacent. For many, the FCTC is done, tobacco control has an answer and the rest will follow. Nothing could be more dangerous than that premise. In fact, if we are not alert and active, the FCTC could turn into yet another treaty gathering dust in ministries and academic institutions around the world.
Allow me to share with you the heady pace of the FCTC negotiations when the WHO enabled the coming together of a multi-sectoral global alliance on tobacco control—an alliance that included the tobacco control fraternity, public health activists, media, and international donor agencies all pulling towards one public health goal. Global governance of tobacco control was organised and focused.
It was a time when donors were leaned on by the then WHO director general, Gro Harlem Brundtland, to do more for tobacco. A doctor and a mother, she would advocate with passion in meetings with the heads of state of Japan, China, and Germany about the immediate need for comprehensive tobacco control legislation. It was a time when heads of state listened to these calls and often reluctantly agreed. Witness the extraordinary turn around underway in Japan and Germany—both have ratified the FCTC.
It was a time when historic knowledge about tobacco control and the need for political action to own responsibility for doing something about it merged. Call it “seizing the opportunity” or call it “the right people at the right place at the right time”, it was a moment when no obstacle was too big and no difficulty was insurmountable in the face of five million avoidable deaths per year.
It was a time when Ted Turner encouraged his UN Foundation to support NGO and media activism as a means of enhancing effective tobacco control, and the Rockefeller Foundation funded innovative work in South Asia. It was a time when Jim Wolfensohn of the World Bank and Carol Bellamy from UNICEF for a few short years joined forces with WHO to talk tobacco control to finance ministers and child rights’ advocates. Wolfensohn even went as far as to nominate the head of Transparency International Germany, Anke Martiny, to join the WHO enquiry into the influence of tobacco companies on WHO policies.
It was a time when the USA’s Bureau for Alcohol, Tobacco and Firearms and the EU anti-fraud unit agreed that decisive international cooperation was need to address cigarette smuggling—and that an FCTC protocol was the way to move ahead.
The struggle went where the damage was dealt. This meant working with the best of international sports organisations like the international football association FIFA and the International Olympic Committee. Benetton, the Italian fashion leader for adolescents, pitched in with a special edition devoted to tobacco control and produced the “Smokers Body” that went on to be the most demanded poster in WHO. It was a time when a partnership between governments and the pharmaceutical industry was launched at the World Economic Forum in front of corporate giants and heads of states.
Three US Federal agencies—the National Institutes of Health (NIH), the Environmental Protection Agency (EPA), and the Centers for Disease Control and Prevention (CDC)—stepped up their international response to tobacco research and surveillance in close partnership with WHO’s Geneva, regional, and country offices. The NIH Fogarty Centers’ international research investment remains the largest such investment in global tobacco control research and has benefited many developing country researchers. The CDC leadership with WHO is putting in place the world’s largest surveillance system, the Global Youth Tobacco Survey—now active in 168 countries and involving 1.8 million youth—which has yielded new insights about the importance of addressing youth tobacco.
It was a time when the commissioners of health and development of the EU acknowledged that tobacco represented a threat to development, and encouraged governments to seek EU funds for tobacco control. It was a time when Philip Morris’s share price slumped and investor confidence plummeted as litigation and public sentiment turned against one of the world’s most popular brands.
That time has passed but the tobacco epidemic continues unabated.
The global network of NGOs under the umbrella of the Framework Convention Alliance is cash starved. Several donors have shifted out of tobacco, with the notable exception of Soros’ Open Society and UK Department for International Development; few new ones have joined the battle. The World Bank is no exception despite the fact that without the outstanding work done by the Bank’s Joy de Beyer, Ken Warner, Prahbat Jha and Frank Chaloupka, the economic arguments required to persuade governments to support the FCTC would not have been heard.
The full recommendations of the WHO commission on tobacco industry tactics have yet to be implemented. No new private–public partnerships to address tobacco control have emerged. The pace of progress on developing protocols to the FCTC has slowed dramatically. The impetus and enthusiasm of many FCTC participants for urgent action is being replaced by slower, bureaucratic, less passionate, and poorly funded initiatives.
Worse, tobacco companies are now being patted on the back for being socially responsible companies as was the case with British American Tobacco (BAT) in Davos last January. Philip Morris stock has recovered over the years—as has its reputation among investors as being a good corporate citizen and the company most likely to deliver a truly safe cigarette. Last week, the company announced that it would buy one of the largest Indonesian cigarette companies, Sampoerna, for $5.2 billion. A JP Morgan strategist, dong what they have done for years—talking up the stock—claimed this was a “win-win deal”. Useful to recall that in Indonesia, almost 70% of men smoke, there are few regulations, TV adverts still sell tobacco, taxes are low, and cigarettes are cheap. Indonesia has few smoking bans in public places.
Yet, Calantzopolous, CEO of Philip Morris International, insisted that the purchase had “little to do with chasing profits in the developing world”. Wall Street cheered the news as physicians and tobacco control advocates in Indonesia watch the death toll increase. Philip Morris will bring modern marketing methods now banned in many countries, and powerful lobbying to their country. Indonesia has not ratified the FCTC.
UNDERMINING THE FCTC
Tobacco control advocates have also identified the toughest impediments to full implementation of the FCTC. From Thailand and Korea I heard about continued tobacco industry efforts to undermine progress. From Venezuela, concerns about the growth of the black market for cigarettes were reported. Simon Chapman from Australia was concerned that political perceptions endure that tobacco control has been “done”, that a decent tobacco control budget is not needed, and that tobacco control is misplaced and the work of left wing nannies! And Stafford Sanders from ASH Australia warned about the continued efforts of the tobacco industry and their surrogates in the hospitality industry to undermine progress.
By now you must be wondering what this has got to do with us. This meeting is dedicated to research. It is about science. It does not make claims to be an advocacy body. We have responsibilities as scientists to advance knowledge. We have responsibilities as privileged citizens to advocate for effective policies to be funded and implemented. Political attention, such as the kind generated during the FCTC, is transient by nature.
What could we as a group do to make a bigger difference?
We could start be calling on all governments to ratify the FCTC before November 2005. That would allow them to join the Conference of the Parties when it convenes in February 2006. My government, South Africa, has been exceptionally proactive in getting a strong FCTC adopted—but has yet to ratify. Our gracious hosts, the Czech Republic, has yet to ratify. China—home to 350 million smokers and where one million people die of tobacco each year—has yet to ratify. And the US President has yet to send the FCTC to the Senate for ratification. Some countries have not ratified for bureaucratic reasons—others may not support implementation. This is not the time for judgment. This is the time for sustained action.
SCIENCE FOR ACTION
There is a need for a stronger science base to be developed if the FCTC and future protocols are to be fully implemented. The research, academic, and NGO community need to take up the intellectual and political challenges of developing robust texts that would be useable when the protocols are finally negotiated between governments. The rationale for the FCTC was to address transnational aspects of tobacco control as it strengthens and stimulates national actions. Issues such as illicit trade, controls on cross border marketing, and international norms for product regulation are classic examples of where protocols were anticipated right from the first debates on the development of the FCTC. We should focus on these areas. Waiting for the WHO or the Conference of the Parties to start the process will delay action for at least a year and maybe more.
EVIDENCE BASED INTERVENTIONS
The FCTC identifies several evidence based interventions that, if applied, could reduce future deaths and disability. Tax increases, total bans on all forms of marketing, bans on smoking in public places, better and more visible warnings, and universal access to effective cessation all work.
There are other provisions in the FCTC that work less well. School education programmes and efforts to limit children’s access to tobacco products are two examples. Too much energy is still being devoted to implementing the least effective measures while avoiding the really effective ones. Researchers have long shown that unless there is a strong and continuous enforcement component built into youth access restrictions, they will not work. And we have known for decades that school health programmes to promote behaviour change fail for all health problems if broader environmental, economic, and legal measures are ignored. More research in these areas is a waste of scarce public funds.
For tax increases to work, they require annual adjustments beyond inflation. Funding for customs and excise controls should accompany tax increases. A protocol on preventing illicit trade and the expanding availability of counterfeit cigarette availability were regarded as an urgent need three years ago—since then the urgency has increased, and the development of the protocol has stalled. This is despite the reality that it would receive wide and rapid support by most countries—and even a number of tobacco companies. Some have floated ideas about how to tighten controls on smuggling, ideas that are worthy of debate and review by independent economists and law enforcement experts.
Internet advertising and sales of tobacco products have increased. Satellite television ads for tobacco continue to be beamed from countries with no laws to those with strong laws. Yet there has been no significant progress in formulating the technological, legal, and political basis for a protocol to address cross border advertising.
Ladies and gentlemen, allow me to make a brief diversion. The Millennium Development Goals dealing with AIDS, malaria, and tuberculosis, has set clear outcome targets and determined the costs required to achieve them. They have gone further and shown what the consequences of inaction will be. Their work has led to substantial new investments in HIV/AIDS.
WHAT CONSTITUTES PROGRESS?
What, we must ask, is an acceptable pace of progress in preventing deaths, misery, and disease from tobacco? Should we settle for measures that have been sustained for two decades in Canada, and over that time achieved a 2% decline in per capita consumption? Should we consider how to move to measures introduced in South Africa that have achieved a rate of decline of about 6–8% a year for the last eight years? Should we aim higher? New York City achieved a 10–12% decline in consumption a year after its ban on smoking in public places was implemented and improved provision of cessation support achieved. And are aggregate data sufficient for us to use in judging progress?
We need to raise our levels of ambition for what is acceptable. Tolerating declines of 2% a year does not seem acceptable in an era when we have the means to reach 10% declines per year. In the UK smoking rates for the poorest groups remain close to 70%, and have virtually not changed for the last 15–20 years. Smoking rates among the most affluent and best educated groups have halved over this period and are now below 20%. The UK experience is repeated worldwide. We need innovative and multidisciplinary research or policy initiatives to develop effective ways of reducing the inequitable gap in smoking related death and disease rates.
We should model and compare the human and economic costs of achieving tougher targets against the costs of our current slow rate of progress. Between the Canadian long term and the New York short term experience must be some lessons for us—lessons about giving heightened priority to quitting, as measures are strengthened to stop initiation.
Beyond that, what policies should we start developing now? I would urge that plain packaging be high on the list. Fifteen years ago a Canadian panel of experts concluded: “plain and generic packaging of tobacco products through its impact on image formation and retention, recall and recognition, knowledge and consumer attitudes and perceived utilities would likely depress the incidence of smoking uptake by non-smoking teens, and increase the incidence of cessation by teen and adult smokers.” Ben McGrady, from VicHealth, writing in a recent edition of World Trade Review, argues cogently for such an approach to be developed despite the potential threats to regulatory freedom in relation to trademarks under the World Trade Organisation’s TRIPS s agreement that would be raised by tobacco companies. Such threats have yet to be tested in WTO which has endorsed the need for countries to implement measures to protect their populations’ health.
POINT OF SALE
In my discussions over the last few years with investment analysts working on tobacco, they have often highlighted the importance of the pack and point of sale as being crucial to the tobacco industries’ profitability. If both were curtailed, the loss to brand value would be considerable. In health terms, that means we would have less tobacco use and less deaths. Saskatchewan‘s law banning point of sale advertisements offers a valuable chance to evaluate the effectiveness of a novel and needed approach that will become increasingly important as companies are forced to close down other marketing media.
The pack and the point of sale will be the final battleground over images. Without the imagery, the colour, and the associated features, a Marlboro or any popular brand will be less appealing. And that will impact on youth initiation!
EXPAND ACCESS TO CESSATION
Your work on cessation and product regulation needs to be better harnessed to impact on public policy. The SRNT family contains the best international expertise on cessation, on product regulation, and on how to implement programmes in health settings effectively. Mike Cummings has recently written that current nicotine replacement therapy (NRT) is simply not having an impact on population trends in tobacco use because it is not used enough. WHO recently highlighted the impediments to full use in its report to the EU. They included issues related to price and access, smoker knowledge of effectiveness, and lack of attention to adherence improving strategies.
That sounds very much like the HIV/AIDS treatment arguments before the South African court case and before several companies agreed, after effective pressure was mobilised, to drop their prices and invest in treatment. NRT and related products are effective and likely to have such huge impacts on current smokers’ future lifespan and quality of life. Where is the outrage from smokers’ and NGOs demanding better access?
Progressive pharmaceutical companies like Merck, Pfizer, Boehringer Ingelheim, GlaxoSmithKline, and others have done a lot to improve access to AIDS treatment for developing countries? Some of these companies are represented here and are active in the field of tobacco cessation. I would urge that you use this conference to forge a stronger coalition between private and public interests to address the issue of access with the urgency that it demands.
We have with us many tobacco industry scientists. For many of you this will be a new experience. They will challenge us with their very well funded research on new product development. They will lure us into a complex debate about the prospects of a biologically inert product being within their sights. A product that could be consumed with low to no risk—except perhaps a whiff of nicotine to keep consumers hooked. A product quite similar to NRT in effect but which is currently unregulated. How should we react—or interact?
Mike Cummings unearthed a 1953 document citing a tobacco company director as saying: “Boy, wouldn’t it be wonderful if our company was the first to produce a cancer-free cigarette? What would it do to the competition?” In 1987 Philip Morris considered that they had the edge over the competitors in this field at a time when the competitors were spending $100 million a year in the USA. The Philip Morris research portfolio then included extensive research into cigarette technology including new package materials, filters, and flavours. In a strategic planning process in 1987 they listed as the top three external threats to their work upward taxation pressure, government regulation of cigarette construction, and regulation of additives. We know why tax was up there. But why product regulation and additives?
In 2003, over $500 million was invested in new product development by BAT and Philip Morris alone. At that level of investment they must be getting close to something big, something safe, something smokers will turn to. Over the last few months a number of us have met with the BAT and Philip Morris scientists to understand whether they were close. My impression is that progress has been made in reducing side stream smoke and in reducing some constituents. But they are still far from having a product with defendable reductions to health risks that consumers will use. Despite that, new products will soon be launched with couched language about smoothness cloaked in cleverly designed packets to give the impression of freshness, and perhaps health, but with no explicit health claims being made. Is this the biggest new deception from an industry that has been found in courts to be masters of deception? Or is it a step towards a truly reduced risk product?
We need to listen to the tobacco industry scientists and demand that they reveal all they know about their products and the intended course of their work. We need to prepare the ground for an FCTC protocol on product regulation fast that could be the basis of deciding whether new products are a ruse or a reality. Without such regulation—based on your science and your evaluation of tobacco industry science—we may repeat the errors of the light and mild cigarettes for another few decades, or we may miss changes that could reduce death rates.
We face a certain death toll over the next decades at least as great as HIV/AIDS. But we are armed with resources that pale into insignificance compared to those being deployed to rightly address HIV/AIDS. There is no UN Global Fund for tobacco, or for cardiovascular disease, cancer, or respiratory disease. There has never been a security counsel debate on tobacco. And there will never be such funds or debates.
Let us not forget that behind data, there is a human tragedy every time someone is diagnosed with lung cancer or emphysema or peripheral vascular disease. The economic cost of tobacco on families, communities, and countries is no less traumatic. We must work more effectively with the powerful networks we are linked to—researchers and scientists representing professionals from the fields of heart disease, cancer, mental health, and substance abuse—they in turn are often close to the corridors of power.
Now is the time to recognise that times have indeed changed. We have an international legal basis for action. Its attainment is the result of concerted efforts by generations of researchers like you working with policymakers, the media, and NGOs.
Now is the time to revisit and improve the governance of global tobacco control. New players must be brought in to deal with new realities. They should be decided on the basis of demonstrated commitment. We should start a process that leads to a better governance system being in place by the next world conference in Washington next year.
The treaty’s full implementation will rest on the shoulders of an emerging cadre of tobacco control researchers and advocates who will no longer be distracted by spurious, tobacco industry backed arguments about the deaths for which they bear direct responsibility.
As scientists and researchers, we have a responsibility to do all that we can to prevent tobacco related deaths and suffering. The only way available to us is to harness the science and the research better and use it to move forward. I am sure we will.