South Africa: from tobacco control leader to loser

When the 17th World Conference on Tobacco or Health takes place in March 2018, the eyes of the global health community will be on the host nation South Africa. Unfortunately, although South Africa was a tobacco control leader in the 1990s and early 2000s, today the country is falling behind. Public interest in tobacco control is flagging, and the network of non-government organisations (NGOs) and public health officials so crucial to progress are lacking both financial and human resources.

South Africa’s national ban on smoking in public places came into force on 1 January 2001. It followed from the first Tobacco Products Control Act (the Act) which was published in 1993, amended in 1997 and then activated by regulations published in 2000. The first ban on smoking in public buildings was introduced 12 years earlier in the town of Edenvale in 1989. Although groundbreaking, it was not noted internationally. However, it sets the scene for public acceptance of smoke-free public places, despite the fact that adult smoking prevalence at the time was close to 40%.

There have been two further amendments to the Act, in 2007 and 2008. These amendments saw the introduction of reduced ignition propensity standards, required all exported products to comply with the importing countries’ laws, strengthened advertising, sponsorship and promotion bans, banned tobacco industry events (other than shareholder meetings), banned confectionery and toys that looked like tobacco products, banned tobacco sales in health and educational institutions, and increased penalties for breaches. Both came into force only in August 2009.

These amendments started with the publication of an Amendment Bill in 2003, which had taken 3 years to draft and then another 6 years to become law. Although they did strengthen some provisions, there were a number of elements that were not enacted, including more comprehensive manufacturing standards and conditions, and requiring industry to provide information and submit new cigarettes variants for approval. Some regulations were poorly worded in a way that created opportunities for the tobacco industry; for example, ‘donations could be made provided they were not for the purpose of advertising.’

Since then, very little has happened. In addition to the above, the Act amendments were designed and drafted specifically to permit large graphic health warnings (GHW). After delays, in part due to disunity within the tobacco control community, the regulations for these amendments were written only in 2013. The World Health Organisation (WHO) Legal Unit in Geneva lauded the regulations as ‘an excellent set of comprehensive regulations’. However, further delays, again created from within the tobacco control community itself, have resulted in those regulations not having been published (5 years after departmental approval). This is despite the fact that the Minister of Health has repeatedly asserted that he wanted, and would legislate for, plain packaging with large GHWs.

The current legislative process has stalled in other ways. The original ban on smoking in public places, while a good start, amounted to a partial ban because 25% of the floor area of an indoor public place could be enclosed and designated for smoking. This loophole persists, with the result that indoor public places are not yet fully smoke free, despite the fact that draft regulations were published and public comments received eight years ago. The display of tobacco products and vending machines are still permitted.

Enforcement of laws that do exist is weak, with failures to prosecute the industry and other offenders for contraventions of the law. A law banning smoking in cars with children under 12 present is not enforced. Another notable gap is the failure to get the Ministry of Finance to change the policies and principles of taxation on tobacco products. Section 5.3 of the WHO Framework Convention on Tobacco Control (FCTC) is largely ignored, opening the way for the tobacco industry to influence policy-makers through donations, sponsorship and other contact with government officials.

Among non-government health organisations, there is support for tobacco control but no unified, driving force for tobacco control-focused lobbying, advocacy and proactive engagement in the legislative process. Leading tobacco control figures in both NGOs and government organisations have retired in recent years, creating a gap in tobacco control-specific knowledge and expertise.

Despite these issues, there is hope. South Africa is home to numerous tobacco control research leaders scattered through universities and research institutes throughout the country. The expertise includes tobacco control economics and taxation, epidemiological surveys, smokeless tobacco and GHWs. The TAG Tobacco, Alcohol and Gambling Advisory Advocacy and Action Group (of which the author is a member) is an NGO with significant experience and is directly involved in tobacco control activism, advocacy, legislation and lobbying. It has a board of 9 directors with wide experience and an expert advisory panel of 10 professionals across a broad range of disciplines. While it has the expertise and passion to drive change, its activities are limited by lack of funding.

South Africa is at a crossroad. Funding is needed for mass media awareness campaigns, lobbying parliament and politicians, attending public hearings in parliament and around the country when the next amendments to the Act take place and much more. Without strong voices of experience and knowledge, the industry will win. Funding is also vital for capacity building, research training tobacco control activists and advocates.

The global tobacco control community coming together in South Africa for the World Conference on Tobacco or Health will be an opportunity to showcase the latest research from around the globe, and grapple with both persistent and emerging challenges. It is also an opportunity to reinvigorate tobacco control in South Africa, and help it again become a tobacco control leader.

Peter Ucko

TAG Tobacco, Alcohol & Gambling

Advisory Advocacy & Action Group, South Africa

peter@tagaaag.org

USA/Canada: universities refuse PMI ‘smoke-free’ funds amid transparency & independence concerns

Seventeen universities in Canada and the USA have issued a joint statement that they will not accept funding from, or pursue work with, the Philip Morris International (PMI)-funded ‘Foundation for a Smoke-Free World’. The statement cites the FCTC, and echoes concerns previously raised by the WHO and leading tobacco control advocates stating: ‘If Philip Morris really wished to establish a ‘smoke free world’ they would stop legal challenges to local and national tobacco control effort and cease advertising and manufacturing cigarettes’.

The latest statement adds momentum to what is rapidly becoming pariah status for the Foundation in the public health community. In addition to the signatories in the letter, which include Harvard T H Chan School of Public Health and Bloomberg School of Public Health at Johns Hopkins University, academics and spokespeople at the London School of Economics and Political Science, University of Southern California and Graduate Institute of International and Development Studies in Geneva are among those who have previously stated that they will not work with the Foundation. This journal has reaffirmed that it will not publish any work funded by the tobacco industry, irrespective of whether such funding is laundered through PMI’s ‘Smoke-Free’ Foundation (http://blogs.bmj.com/tc/2017/10/23/why-tobacco-control-still-wont-publish-tobacco-industry-funded-work-even-if-the-funding-is-laundered-through-pmis-new-independent-foundation/).

Smoke-Free Foundation president Derek Yach has repeatedly claimed that the Foundation is truly independent from PMI, drawing heavily on a 2009 paper published in this journal entitled Criteria for evaluating tobacco control research funding programs and their application to models that include financial support from the tobacco industry (http://tobaccocontrol.bmj.com/content/18/3/228.info). Yach cited the paper in an article published by the Lancet in October 2017 and asserted that the PMI Smoke-Free Foundation meets the eight criteria outlined.

However, the authors of the paper have unambiguously countered his representation of their recommendations. After submitting a response to Yach’s article to the Lancet and following up multiple times over a period of 2 months with no response, the paper’s authors Joanna Cohen and Thomas Eissenberg retracted their Lancet correspondence and published it through their own channels.

Cohen and Eissenberg note that the Foundation’s independence is compromised from the outset by having four predetermined research foci, in line with the industry’s track record of determining agendas that benefit the industry behind closed doors. They also note that the lack of meaningful consultation before launching the Foundation rendered it highly likely that many experts would not engage with it—exactly as is now happening—further compromising its independence. Further, while Yach makes much of disclosure, Cohen and Eissenberg note that the criterion about disclosure also requires prohibition of some relationships—and the Foundation’s bylaws are silent on this aspect.

Cohen and Eissenberg’s criticisms are echoed in more recent analysis published by the McCabe Centre for Law and Cancer, which examines the Foundation’s recently announced Pledge Agreement. It notes that the Foundation’s focus on ‘ending smoking’ is to be pursued only in the context of alternative products and harm reduction, highlighting that ‘Patently, Philip Morris has a significant commercial interest in alternative products/harm reduction, whereas prevention of uptake and cessation of use, without replacement by other products, are not in its interests’.

It concludes that: ‘it would not be unreasonable to form a picture which is different from the one Yach sees, one in which Yach’s ‘independent foundation’ is more akin to a program of Philip Morris, with Yach and the Foundation’s Directors, whoever these come to be, having a degree of day-to-day autonomy in their operations (just how much autonomy is unknowable), but with the fundamental settings put in place by, and enforced, by Philip Morris’s USD960 million’.

Examination of the Foundation seems to reveal history repeating itself, yet again.

More information and links are published on our website at: http://blogs.bmj.com/tc/2018/02/01/philip-morris-smoke-free-foundation-questions-about-independence-and-transparency-while-top-universities-distance-themselves/.

Austria: new government a tobacco industry victory?

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Figure 1

Japan Tobacco International paid €20 000 to the city of Vienna to place ashtrays in the form of a large cigarette throughout the city, including at playgrounds. The ashtrays have no health warnings as required under the EU tobacco products directive. EU, European Union.

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Figure 2

A typical tobacco shop in Vienna, showing vending machines on the shop exterior, water pipe display in the window and prominent tobacco advertising.

In Austria, the conservative Austrian People’s Party (Oesterreiche Volkpartei (OeVP)) won the 2017 elections and negotiated with the third-largest party, the right-wing nationalist Freedom Party of Austria (Freiheitliche Partei Oesterreichs, FPOe) to form a new government. In its election campaign, the FPOe had promised to attack the tobacco law, which had been passed by the Austrian parliament in 2015, supported by the SPOe (social democrats), OeVP and Green Party.

The tobacco control law followed European Union (EU) directives, but also WHO recommendations to ban shisha and vaping where smoking is forbidden, and ban smoking in all hospitality venues without exceptions. A three-year transition period had been granted to the hospitality industry (the longest in Europe, for ‘confidence’) before the law was supposed to enter into force on 1 May 2018. The FPOe’s promise, spearheaded by its leader Heinz-Christian Strache, to roll back even this modest proposal raises concerns that its campaign was supported by the tobacco industry.

Although Austria no longer has a domestic tobacco industry, historic connections between the tobacco monopoly administration and the ministries of finance and economy continue. There are 5784 tobacco shops, 2417 other stores including gas stations, 933 hospitality venues and some food markets that are allowed to sell tobacco. Tobacconists, which also sell newspapers and a variety of goods for children, are a powerful lobby. Tobacco products are advertised in and around their shops (which are exempt from smoking bans), and they distribute free cigarettes whenever a new product is put on the market. Theoretically tobacconists are obliged to control the age of young people buying tobacco, but enforcement is extremely limited.

Cigarettes are available around the clock in Austria, making them more accessible than staple foods. The 6500 vending machines throughout the country are plastered with tobacco advertising, an effective loophole to circumvent advertising bans. Warning regulations of the EU tobacco product directive are ignored and tobacconists pretend that the machines are ‘child-proof’ by electronic age control, which is ineffective. The price for Austria’s lack of effective tobacco control is shamefully high youth smoking prevalence, particularly compared to other high-income countries. A 2013 OECD report on 26 states listed Austria as having the highest smoking prevalence of children aged 15, a position it has held since 1994. In the last survey, 18% of Austrian children aged 15 reported to be daily smokers.

Austria introduced smoke-free workplace legislation in 2001 (with the exception of the hospitality industry), but a 2006–2007 survey found only 72% of non-smokers reported a smoke-free or nearly smoke-free workplace. Five per cent suffered from daily passive smoking for >5 hours per day, 8% for 1–5 hours per day, 12% for <1 hour per day and 3% worked at home, where 10% of non-smokers reported secondhand smoke exposure. A ban of smoking in public buildings in 2005 was not enforced and schools only became smoke-free in 2006 (excluding non-compulsory schools).

It was not until 2009 that sanctions for violations of non-smoker protection were introduced. Even then, loopholes for the hospitality industry made many of the regulations virtually meaningless. Although the hospitality industry was obliged to provide non-smoking rooms, an exception was made for small, single-room enterprises. In premises below 50 m², the innkeeper still can choose to be a smoking inn, if indicated by a sign. Owners of premises between 50 and 80 m² could apply for the same exemption at the building inspection. As expected, most small bars and pubs remained smoking for fear of losing guests to neighbouring smoking establishments.

Inns >80 m² were allowed to stay without separation until mid-2010. Afterwards, they were required to prevent smoke from entering the non-smoking section, but the law did not give detailed instructions. No authority was tasked with enforcement, and police, work inspectors and food inspectors were not allowed to control smoking in the hospitality industry. Reporting of violations was left to guests, but they were required to show proof by taking photos and knowing the name of the violator. The Austrian Council on Smoking and Health and other health non-government organisations received numerous reports of guests who did report violations facing abuse and harassment, including being labeled ‘squealers’, having their photo posted as unwanted guests at the entrance of premises they had reported, and being illegally forbidden to enter.

Among all OECD countries only Austria, Latvia and Slovakia failed to reduce their smoking prevalence since 2000. Recent data indicate that prevalence is increasing among women, persons with low education, unskilled workers, unemployed and migrants in Austria. Since 2007 Austria has consistently had the lowest score in the Tobacco Control Scale of the European Cancer Leagues, primarily due to the influence of tobacco industry and tobacco trade. Meanwhile, both public opinion and the advice of medical science were ignored by policy-makers.

Despite media activities by the chamber of commerce (partly in cooperation with the tobacco industry,) Austrian opinion polls over the last decade have consistently showed a majority in favour of a smoking ban in the hospitality industry. The FPOe has a higher proportion of smokers than other parties, both among their voters and their delegates. Its leader Heinz-Christian Strache is a smoker and in his election campaign had promised to attack the smoking ban. He spread fear among wait staff that they would lose their job after a ban and promised tobacconists that their business would not decrease if they voted for him.

OeVP voters are 85% non-smokers and their non-smoking new leader Sebastian Kurz had promised that he would stick to the tobacco law, which had been fully supported by his party in 2015. However, during the negotiations with Strache, media reported that he was willing to sacrifice the tobacco law and trade it for the tolerance of FPOe to sign the EU–Canada Comprehensive Economic and Free Trade Agreement.

The reports caused alarm among health professionals, both in Austria and internationally. Numerous associations appealed to Kurz not to give in, including the European Public Health Alliance, Smokefree Partnership, member organisations of the European Network for Smoking and Tobacco Prevention, Society for Research on Nicotine and Tobacco Europe, UK Centre for Tobacco and Alcohol Studies, WHO Collaborating Center for Tobacco Control, and numerous other international medical groups and research institutes, as well as scientific associations of Austrian medical specialists (such as cardiologists, oncologists and pneumologists) and other health professions.

During coalition talks, however, Kurz and Strache did not listen to science, but to lobbies like the tobacconists, who reported proudly on their influence on the new government in their trade newspaper. The decision sparked a strong reaction among the Austrian public; a petition to reverse the decision attracted nearly 100 000 signatures within the first 24 hours.

Austria’s already weak and inadequately enforced smoke-free law is now slated to be annulled. Prime Minister Kurz fulfilled the wishes of his smoking coalition partner Strache to cancel the smoking ban in all hospitality venues. He even agreed to weaken the present regulation, in which innkeepers of small venues are allowed to decide themselves to expose their guests and employees to tobacco smoke. This irresponsible regulation will be extended now to venues up to 75 m², which will encompass many more establishments.

Kurz was minister of foreign affairs and is aware that Austria ratified the FCTC in 2005. As prime minister, he is supposed to take over the presidency of the EU in July 2018. Austria will lead the European group at the WHO FCTC Conference of the Parties in October in Geneva. Kurz could have used this position to demonstrate that Austria is improving in tobacco control, but he decided to slap the face of most of his voters and colleagues from OeVP in order to please a reactionary right wing, protobacco party.

This capitulation not only contributes to Austria’s lack of credibility in global tobacco control, but it is likely to also further exacerbate Austria’s disastrous tobacco epidemic. The smoking ban reversal and other decisions about the tobacco control law were decided by the party leaders Strache and Kurz and a small group from their parties in the coalition talks.

It remains to be seen if members of parliament are marionettes of their party leaders or able to decide according to their conscience and the wishes of the majority of Austrian voters.

(This is an edited extract of an article published on the Tobacco Control website. The full article and links can be read at: http://blogs.bmj.com/tc/2018/01/09/austrias-new-government-a-victory-for-the-tobacco-industry-and-public-health-disaster/).

Manfred Neuberger

Medical University of Vienna

Austrian Council on Smoking & Health

manfred.neuberger@meduniwien.ac.at

UK: PMI new ‘premium smoking experience’ launched in key ‘smoke-free future’ market

Observers of Philip Morris International’s push for a ‘smoke-free future’ will recall the announcement by the company in mid 2017 that it was launching a ‘smoker conversion’ programme in the UK. Backed by hundreds of ‘brand ambassadors’, the company claimed that it was so serious about moving to a smoke-free future that it was offering £50 to brand ambassadors for every smoker they managed to ‘convert’ to its heat-not-burn product.

Despite its ‘deadly’ serious intention, the company announced in July that the UK would be the first market in the world to launch Marlboro Touch, which features ‘many quality enhancements and a distinctive blue design’. Among the features of the rebrand are a ‘soft-touch’ pack and firm filter, designed to add an overall feeling of quality, and a ‘premium’ smoking experience (does it give you a better quality of lung cancer?), all at an ‘affordable price’.

In a country that fully transitioned to plain cigarette packaging only last year, the ‘rebrand’ sounds like a desperate attempt to undermine one of the tobacco industry’s most dreaded policies. Those IQOS brand ambassadors must be fuming about losing out on their £50 pocket money.

USA: tobacco investment conflicts force CDC Director to resign

The Center for Disease Control Director Brenda Fitzgerald was forced to resign in late January after it was revealed that she had traded in tobacco stocks after taking up her position. While she had pledged to avoid any work that would affect her holdings, the recusal that would have been imposed by her interests was considered so broad that it would limit her ability to carry out her duties effectively.