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Worldwide News and Comment
  1. Marita Hefler
  1. Wellbeing & Preventable Chronic Disease, Menzies School of Health Research, Casuarina, NT 0810, Australia
  1. Correspondence to Dr Marita Hefler, Wellbeing & Preventable Chronic Disease, Menzies School of Health Research, Casuarina, NT 0810, Australia; marita.hefler{at}menzies.edu.au

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All articles written by Marita Hefler unless otherwise attributed. Ideas and items for News Analysis should be sent to: marita.hefler@menzies.edu.au.

World: World No Tobacco Day around the globe

World No Tobacco 2019 was celebrated across the globe on 31 May. The focus this year was on lung health, with organisations and individuals highlighting the many ways that tobacco can ‘take your breath away’. In this edition, we provide some highlights from social media.

Figure 1

Photos posted by CEHURD, a non-profit health and human rights organisation in Uganda supporting vulnerable communities. Source: Twitter/CEHURD.

Figure 2

In Ghana, the dangers of shisha smoking were a major theme for World No Tobacco Day. Source: Twitter/FDA Ghana.

Figure 3

Mock-up of Canadian plain package in slide and shell format.

Figure 4

Ad by tobacco company JTI-Macdonald opposing plain packaging.

Brazil: government acts to recover tobacco costs from industry

The local subsidiaries of British American Tobacco and Philip Morris between them have 90% of the Brazilian cigarette manufacturing and trading market. While the enormous health costs induced by use of their products are borne by the country, the majority of profits go abroad. On 21 May this year, the Brazilian Office of the Attorney General took action to change that, by filing a civil public action for the tobacco companies to pay the state for the cost of treating whose diseases are caused by tobacco products.

If successful, the tobacco companies will be required to reimburse Brazil’s public health network the costs for the last 5 years of providing treatment for 26 health conditions arising from exposure to cigarette smoke. The case also includes a request for projected future costs for both healthcare and moral damages. Tobacco use is responsible for 150 000 deaths per year in Brazil, with costs estimated to be as high as US$14.1 billion.

The move was praised by public health groups including the WHO and Campaign for Tobacco Free Kids (CTFK). CTFK President Matthew Myers stated that the lawsuit “marks a crucial step forward on holding tobacco companies responsible for their decades of deceitful advertising and marketing practices that hid the dangers of smoking from the public and purposely targeted young people.” Conduct listed by the Brazilian Office of the Attorney General includes omission and manipulation of information about the harms of smoking, passive smoking and the addictive nature of nicotine. Deceptively marketing ‘light’ cigarettes as less harmful, and youth-targeted advertising and promotion were also cited.

BAT’s local subsidiary Souza Cruz disputed that it and the PMI local subsidiary are responsible for 90% of the Brazilian tobacco market, stating that illegal cigarettes from Paraguay make up about half of the Brazilian domestic market (a somewhat ironic claim, given research has found both BAT and PMI helped seed the illicit tobacco market through Paraguay from the 1960s; see https://theconversation.com/how-paraguay-dumps-billions-of-illicit-cigarettes-on-the-global-market-107679).

While similar lawsuits have successfully recovered tobacco-related costs from the tobacco industry in other countries, including the USA Master Settlement Agreement, if successful this case will be an important precedent in Latin America.

USA: BEVERLY hills City Council OUTLAWS tobacco sales

Beverly Hills City Council made history on 4 June when it voted to outlaw all tobacco sales within the city. From 1 January 2021, sales will not be permitted from convenience stores, gas stations, pharmacies and grocery stores. Very limited exemptions apply for hotel concierges to sell direct to hotel guests, and a small number of private cigar clubs.

Beverly Hills was an early leader in introducing smoke free restaurants and bars; with this latest move it may be an early leader in changing history, as noted by Doug Blanke Executive Director of the Public Health Law Centre at the Mitchell Hamline School of Law in Saint Paul, Minnesota, who said: “The tobacco epidemic is the greatest manmade catastrophe of all time: it’s on track to kill a billion smokers before the century is out. But we may look back and say that this was the day that changed all that…with this bold action, Beverly Hills is showing the world an alternative path. A path to zero tobacco deaths. To a world where we don’t just ‘control’ tobacco products, we phase them out completely. A world free of tobacco-related death and disease.”

Executive Director of Action on Smoking and Health (ASH) Laurent Huber stated: “I’ll never understand why a product that causes diseases and harm to nearly every organ of the body can be sold at every gas station and drug store”. No other hazardous, proven-deadly product receives the same free pass to be sold for mass consumption. Beverly Hills is the first domino falling for tobacco sales, and other jurisdictions with no doubt soon follow their lead.”

More information about the decision is on the Tobacco Control blog https://blogs.bmj.com/tc/ and ASH website at https://ash.org/beverly-hills-passed/?fbclid=IwAR3h15epoSjcJWNGOHSNfJyJ-lxRQc_T8KShiOcMUJzBpY8i2HU-f1OBk9E.

CANADA: plain packaging regulations adopted; & action on FCTC 5.3

On 1 May 2019, Canada’s Minister of Health Ginette Petitpas Taylor announced final plain packaging regulations to come into force on 9 November 2019 at the manufacturer level, and 7 February 2020 at retail. The plain packaging requirements are the most comprehensive globally to date, and follow extensive work by advocates and by the Canadian Department of Health.

Health organisations in Canada have been advocating for plain packaging since the late 1980s. In 1994, in the world’s first parliamentary examination of plain packaging, the Canadian House of Commons Standing Committee on Health recommended the measure. The committee hearings revealed the intensity of tobacco industry opposition and arguments. Twenty-five years later, Canada has finally adopted regulations.

Plain packaging was included in the platform of the Liberal Party, led by Justin Trudeau, in the campaign for the October 19, 2015 national election that resulted in a Liberal majority government. A public consultation was launched May 31, 2016. Bill S-5, a bill which elaborated on regulatory authority, had all-party support and received Royal Assent May 23, 2018. Draft regulations for consultation were released on 22 June 2018.

Throughout the process tobacco companies were strongly opposed, engaging in a multi-million dollar lobbying and public relations campaign. Familiar arguments were used, many first heard during the 1994 parliamentary hearing—that plain packaging would be ineffective, would cause contraband, and would infringe constitutional and international trade obligations. Convenience store associations and the National Coalition Against Contraband Tobacco, organisations funded by the tobacco industry, also campaigned against the measure. The cigar sector lobbied unsuccessfully for an exemption.

The regulations apply to all tobacco products and set numerous world precedents. A key world first is the slide and shell package format requirement for cigarettes, although with an additional 24-month transition period. Slide and shell is the traditional package format in Canada and has a much larger front/back surface area than flip top packages. The result is that Canada will have the world’s largest package warnings measured by surface area (square centimetres).

Other world precedents include: banning brand names evoking a colour or filter characteristic; requiring the standard colour (drab brown) on the package inside; requiring a cigarette diameter of a minimum 7.65 mm and a maximum 8.0 mm, thus banning slims and superslims cigarettes (New Zealand has a 7.0 mm minimum and 9.0 mm maximum); establishing a maximum cigarette length of 85 mm (New Zealand maximum is 95 mm); allowing cigarettes in only two lengths, 70–73 mm and 82–85 mm; and establishing a little cigar diameter of minimum 7.0 mm and 8.5 mm maximum.

Other measures already implemented elsewhere include: banning branding/markings on the cigarette; applying requirements to cigarette papers and filtered tubes and their packages; and banning filters with a tubular/recessed hole characteristic.

Fundamental to achieving the Canadian regulations was the plain packaging precedent set by Australia, followed by other countries such as the UK, France and Ireland.

The international advances in the Canadian regulations continue Canada’s history of tobacco packaging reforms. Canada’s previous world firsts include requiring health warnings on 20% of the package front/back (1989); a warning size of 35% (1994); warnings at the top of the front/back surfaces instead of the bottom (1994); warnings in black and white (1994); a warning size of 50% (2001); use of graphic pictures in warnings (2001) and requiring health inserts in cigarette packages (2001).

In addition to the plain packaging measures, May saw progress on fulfilment of FCTC Article 5.3 measures. On 9 May 2019 the Department of Health announced the launch of a website for public disclosure of information about meetings on regulatory and scientific/technology matters involving health department staff and tobacco and vaping product industry representatives. The website address is https://www.canada.ca/en/health-canada/services/health-concerns/tobacco/meeting-summaries-tobacco-vaping-industry.html.

Rob Cunningham

Canadian Cancer Society

rcunning@cancer.ca

India: action against spitting to help curb smokeless tobacco & areca nut use

The Global Adult Tobacco Survey India Report 2016–2017 found that nearly 200 million Indians aged 15 to 69 years use smokeless tobacco (SLT) in some form. The majority of SLT products are used in conjunction with areca nut, which is used by nearly 224 million adults (24% of the population).

Areca nut and SLT use is typically accompanied by spitting. Thus use of these products not only causes adverse health outcomes for the users themselves, it also exposes others to infectious diseases such as tuberculosis. The practice is also responsible for defacing public premises and properties. Together, areca nut and SLT use impose a huge health cost on individuals and the state, in addition to large amounts of public money required for cleaning and upkeep of public premises tarnished by areca nut and SLT-induced spitting.

To address the issues created by areca nut and SLT use, state and local bodies in India have made regulations against such behaviour in public places. Locations which have implemented regulations include Bombay, Bihar, Karnataka, Goa, Andhra Pradesh, West Bengal, and Tamil Nadu.

Several other states and corporations prohibit spitting in public places and impose penalties ranging from 200 to 500 Rupees (USD3-7). Many have used novel approaches to address the issue. The Ahmedabad Municipal Corporation (AMC), under the ‘smart city’ project, and to upgrade its ranking in the Swatch Bharat (Clean India) campaign, takes action against people spitting, urinating or littering in public places. Daily fine collection in the city from offenders has been as high as 100 000 Rupees (USD3000). To monitor spitting by persons from moving vehicles, AMC recently used an automatic number plate recognition system using closed circuit television camera footage and fined a man for spitting pan masala at a traffic junction.

In 2018, the Pune Municipal Corporation gave 270 spitters a mop and a bucket of water and required them to clean up the road, in addition to levying a fine of 150 Rupees (USD2). In 2016, the Brihanmumbai Municipal Corporation of Mumbai introduced an initiative by hiring 22 private agencies authorised to appoint 720 'Clean-up Marshals' with powers to impose fines of up 1000 rupees (USD 13) at 778 identified places within their jurisdiction.

In March 2019, The New Delhi Municipal Council started a mobile squad to collect fines from any person spitting, littering or encroaching on public land in the municipal area of the city. It plans to use mobile point of sale machines, which will accept debit and credit cards, for collecting fines from offenders on the spot.

Indian Railways has banned spitting in railway premises with all regional and zonal offices directed to implement the ban. A similar restriction on spitting also exists in various Metro Rail Corporations across the country. The railways also prohibit the sale of bidi, cigarette, gutkha and other tobacco products on railway premises and in trains. The measures have inspired India’s neighbours; the Pakistan Medical Association has suggested that Ramadan provides an excellent opportunity for those using smokeless tobacco to quit, and called for the Pakistan Railway authorities to declare train compartments and railway stations ‘tobacco, paan, Chhalia and Gutka free’.

The need for a central law to address spitting has been raised in the upper house of the Indian Parliament. The Health Minister of India stated that, “There is no central law enacted and administered by the Ministry of Health and Family Welfare to ban spitting in public places. However, the Central Government is issuing an advisory to the State Governments to take suitable action to ban spitting in public places.” He acknowledged the high rates of tuberculosis in the country and added that it was primarily an airborne disease mainly transmitted through coughing and sneezing.

Spitting by a tuberculosis patient can also spread infection. With more than 2.8 million cases of tuberculosis in India, spitting in public places poses a serious risk of spreading both tuberculosis and other infectious diseases. Given that public spitting is primarily connected to areca nut and SLT use, it is imperative that national, state and local health authorities take action towards putting an end to the ‘great Indian spit’. Anti-spitting mass awareness campaigns must become an integral part of national tuberculosis and tobacco control programme to achieve UN Sustainable Development Goal targets. A ban on spitting in public places will have the dual benefit of reducing both communicable diseases and SLT and areca nut use.

Ravi Mehrotra

Amit Yadav

ICMR National Institute of Cancer Prevention and Research, India

WHO FCTC Global Knowledge Hub on Smokeless Tobacco

ravi.mehrotra@gov.in

Pakistan: new tax and other progress, but stumbles on FCTC 5.3

World No Tobacco Day saw the announcement of a new tobacco tax in Pakistan, with a levy of 10 rupees (approximately US6c) per pack, an increase of approximately 10% on the cheapest cigarette packs. The tobacco tax was announced in conjunction with a planned levy of 1% on sugary beverages. The Pakistan health minister Dr Zafar Mirza, formerly with the WHO, was quoted by media as stating that the tax revenue raised would be used for public health benefits.

The new levy will be a welcome initiative in Pakistan, which has lagged in tobacco control measures in recent years. An editorial in the media outlet news.com.pk on World No Tobacco Day highlighted the need for strong action to reduce the death toll of 170 000 Pakistani lives lost each year to tobacco, and address youth smoking. It is estimated that 1200 children start smoking each day in the country, and over 20 million young people under 15 are current smokers. The editorial noted that tobacco control laws are weak, and enforcement is poor for existing laws.

The health minister has stated that strengthening tobacco control is an important priority of the government, and specifically mentioned it in his address to the World Health Assembly in May. Despite this professed commitment, recent messages have been mixed. In a positive move, on 22 May 2019, he tweeted a photo of a letter to the Pakistan Tobacco Company (a subsidiary of BAT) demanding a written reply to notification of advertising restriction violations.

However only a few weeks earlier in April, Prime Minister Imran Khan gifted valuable free publicity to BAT when he was filmed and photographed accepting a 5 million rupee (US$34,000) donation from the BAT regional director for the country’s dam fund. Responding to critics on Twitter who pointed out that the prime minister’s action was in contravention of FCTC Article 5.3, Dr Mirza responded that “tobacco contribution to Dam Fund has no link whatsoever to Government’s Anti-Tobacco Policy. Prime Minister Imran Khan is firmly committed to Pakistan’s obligations under the Framework Convention on Tobacco Control. Health is a very high priority for the Prime Minister.” Around the same time, there were reports that the government had also accepted a donation from Pakistan Tobacco Company of 20 million rupees (US$135,000) for the Shelter Home project. Such a fundamental lack of understanding of the scope of FCTC Article 5.3 is a troubling sign.

The public health community will be watching closely to see whether the glimmers of progress continue or if Pakistan continues to flounder.

World: Philip Morris attempts to hijack world no tobacco day

In a move met with scorn by the public health community, Philip Morris International issued a media release ahead of World No Tobacco Day calling for the day to be rebranded as World No Smoking Day. The company followed its well-worn narrative that ‘people will just continue to smoke’, as if it is a naturally occurring epidemic, for which it reluctantly meets demand, rather than a tobacco industry-caused disaster supported by a vast army of lobbyists, enormous marketing budgets, policy interference and exploitation of weak tobacco control laws in ‘growth markets’.

Naturally, the call aligned neatly with PMI’s commercial interests of expanding its product range to meet its commercial objectives, and did not miss the opportunity to attempt to divide the public health community by painting its opponents as pursuing ‘old ideological fights’ that ‘misdirect the conversation’. It finished with a segue to its latest marketing gimmick, the ‘unsmoke’ campaign. Apart from the gall of calling on global public health to fall into line with its commercial priorities, the call is breathtakingly insensitive to the devastating toll of SLT use, particularly in south Asian countries such as India, Bangladesh and Pakistan.

While PMI labelled its stunt a ‘bold call to the public health community’, the public health community response was well articulated by Director of The Union’s Department of Tobacco Control Dr Gan Quan, who said: ‘the recent campaign launched by Phillip Morris International (PMI) to rebrand WNTD as World No Smoking Day not only reveals its indifference to the millions of people suffering from diseases caused by smokeless tobacco products, but also serves as a reminder for us that this is simply another tactic by PMI to promote its deadly products’.

Interestingly, the ‘independent’ but solely PMI-funded Foundation for a Smoke-Free World also tweeted on World No Tobacco Day, featuring a video suggesting that people leave the last cigarette “Unsmoked”. One wag tweeted: “Comedy corner. A Philip Morris-funded “Foundation” consistently claiming independence mirrors wording from the Philip Morris “Unsmoke” PR charade. And so far all of one retweet – from the organisation’s own CEO.”

World: philip morris ventures into life insurance

Philip Morris appears to be on a run of attempting to break comedy; before its futile WNTD hijack attempt, in April 2019 news broke that the company was venturing into the life insurance business. Through a wholly owned subsidiary, policies will initially be offered in the United Kingdom, however there are plans to expand to other markets. It plans to offer discounts to people who quit smoking, switch to its heated tobacco product IQOS, or other vaping products. Not a bad business model: get people addicted to your most deadly product, wean them on to another addictive product and pocket the life insurance premium.

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Footnotes

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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