Philip Morris (PM), the world’s largest transnational tobacco company, may try to hide its corporate head under the wing of its parent company, Altria, these days, but it cannot escape the attentions of health advocates trying to make it accountable for its actions. If Altria’s annual stockholders’ meeting in April was anything to go by, when it faced a record level of protest accusing it of spreading the smoking epidemic around the world, things can only get worse.

Altria’s worldwide earnings are now so large that they dwarf the entire economic activity of many a small nation whose citizens are daily encouraged to smoke Marlboro cigarettes. In 2004, its net revenue was $89.6 billion, more than two and a half times the gross domestic product of Kenya, seven times more than Nicaragua’s, and 12 times that of Malawi, one of the largest tobacco producers in the world (and the most tobacco dependent).

Not surprisingly, Altria’s chief executive, Louis Camilleri, is well rewarded for his group’s success. Although on a basic salary last year of “only” $1.5 million (he has a 16% rise for this year), his stock options and other remuneration, much of it performance related, took his annual earnings to around $6.7 million. At more than $18 000 per day, every day of the year, that’s probably still enough to be worth anyone getting out of bed for, even when they know their big day will be marred by a bunch of protesters. Even when those protesters relate first hand experience of the death and disease the company’s number one product causes to millions of sufferers, or customers who have chosen to smoke, as Mr Camilleri may prefer to think of them.

At this year’s annual meeting in East Hanover, New Jersey, not only did the Nightingales fly in again (see USA: nightingales sing at PM’s AGM. Tobacco Control 2004;13:218), but a truly diverse and international group took part. Some were well known from previous protests, but others who came new to the fray, many from the very markets health advocates are most concerned about, also made themselves heard.

Singapore: laying down the tar Always ahead of the pack with its tobacco control policies and ever changing, creative new ways of bringing the message home, Singapore recently came up with another first. A series of health education “advertisements” were painted on road surfaces, like this one on the pedestrian crossing area at a busy street junction. Singapore’s prevalence of daily cigarette smoking among adults declined significantly from 15.2% in 1998 to 12.6% in 2004, with males down from 27.1% to 21.8%, though young females (18–29 years) were up from 5.2% to 6.6%.

The Nightingales are a group of registered nurses from more than 25 American states who, like the other protestors, became shareholders in Altria so they could speak out about the tobacco caused suffering they witness in their daily work (www.nightingalesnurses.org). “Altria claims to be trying to be responsible,” said Ruth Malone, associate professor of nursing at the University of California, San Francisco, addressing Mr Camilleri, as she recalled lung cancer patients for whom she has cared, “but do the top executives and investors really fully understand the unspeakable suffering that cigarettes cause with ordinary use? If not, why not? If so, how can you possibly continue to promote these deadly products?”

The nurses displayed a banner made up of letters sent to the company by grieving families and dying consumers, and shared stories of the suffering they witness in caring for tobacco users and their families. They also spoke to several of the proposed shareholder resolutions, including one addressing cigarette sales to pregnant women.

Among other protestors, more than 100 young people and adults from India, Indonesia, Nigeria, Thailand, California, Hawaii, and the USA turned up at the meeting, organised by Essential Action and several youth empowerment programmes, with some 30 going inside to denounce PM’s global expansion. Since Altria is celebrating Marlboro’s 50th anniversary this year, also the 50th anniversary of PM’s overseas expansion, demonstrators marked the anniversaries outside the meeting with a “Happy 50th Deathday” cake, black balloons, a 15 foot (4.6 m) high Marlboro pack labelled “50 Years of Death”, and photographs of the company’s tobacco promotions around the world.

This year’s annual meeting of Altria attracted a diverse group of demonstrators, including the Nightingales (upper panel), a group of registered nurses from more the 25 US states. Other demonstrators marked the 50th anniversary of Marlboro with a “Happy 50th Deathday” cake and card.

Inside the meeting, Camilleri was presented with a “Happy 50th Deathday” card. As he started to list all the company’s “socially responsible” activities around the world, such as Asian tsunami relief, support of domestic violence victims, and food for the hungry, about two dozen youths and adults covered themselves in black death shrouds bearing skull images and large “Happy 50th Deathday” stickers, and stood up. Mr Camilleri interrupted his speech to order everyone to sit down and stop blocking other people’s view, whereupon two protestors then moved to the aisle and stood facing the audience for the remainder of the meeting. It is good to see Big Tobacco being confronted by increasing levels of protest by those speaking up against what it is doing around the world.

Altogether, protest speeches accounted for around an hour of Altria’s annual shareholders’ meeting. It can only get worse.