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Worldwide news and comment
  1. Marita Hefler
  1. Wellbeing & Preventable Chronic Disease, Menzies School of Health Research, Casuarina, NT 0811, Australia
  1. Correspondence to Dr Marita Hefler, Wellbeing & Preventable Chronic Disease, Menzies School of Health Research, Casuarina, NT 0811, 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

On 26 July the latest WHO Global Tobacco Report was launched in Brazil. While it showed progress in expanding the number of people globally who are covered by at least one MPOWER measure, it starkly highlighted how much remains to ensure that the right of all people to good health is fulfilled. As implementation of Framework Convention on Tobacco Control (FCTC) measures progresses, the tobacco industry—like any aggressive vector—continually mutates, finding new forms and strategies to attempt to convince politicians and the general public it has changed. Among its key strategies are infiltrating and subverting agendas for health and development, as well as co-opting allies (whether wilfully ignorant, or simply willing to take blood money) to sing from its song sheet. In this issue, we look at recent events which highlight manoeuvres to impede progress to address the human-caused, greed-driven disaster that is the tobacco epidemic.

New Zealand/USA: PMI, JUUL and the exploitation of indigenous peoples

Like most indigenous peoples who have experienced colonisation, the Māori of Aotearoa/New Zealand have disproportionately high smoking prevalence. Among adults, 13% of all New Zealanders smoke, compared with 31% of Māori. Tobacco was not part of Māori culture before colonisation, and there is a strong tradition of Māori resistance to it. Central to this resistance was an emphasis on the need to shift attention away from individuals to commercial tobacco companies and their products. Unfortunately, Māori resistance to tobacco has faced significant challenges in recent years, not least due to substantial disinvestment from tobacco control, including Māori-focused activities.

Now, a new challenge is emerging: promotion of new products, supported by targeted discounting to Māori. A July media report (available at https://www.newsroom.co.nz/2019/07/11/677880/big-tobacco-targeting-maori-with-e-cigarettes%23) detailed how Philip Morris is running marketing and promotion campaigns to sell its heated tobacco product IQOS at half price, or on a free trial basis, in areas with high Māori populations such as sports clubs, as part of a process the company calls ‘community activations’ or ‘community outreaches’. The company has hired a Māori ex-journalist as their communications person, and a Māori woman as their community relations lead; she attributes the ‘extensive hyper-care’ programme run by Philip Morris International (PMI) for many people taking up the product.

Co-opting Māori to lead the sales push has been strongly criticised. Longtime tobacco control advocate Shane Kawenata Bradbrook said in an interview with Māori Television: “Before they used to just kill us – now they’re hiring our people, and saying ‘get out into your communities and sell this stuff directly to your community’…there’s a prime example (of exploitation of our people). Use your own people to get into your community, sell it as a good product. At the end of the day, who are you pleasing? Ultimately, it’s the shareholder and the CEO and all the other machinery behind these big tobacco companies.” (Interview available at: https://www.maoritelevision.com/shows/te-ao-moana/S01E007/te-ao-moana-series-1-episode-7).

Earlier this year, PMI stated that it wanted to phase out sales of its combustible cigarette products in Aotearoa/New Zealand by the end of the year—but linked the commitment to the government offering tax breaks and ‘appropriate’ regulation for alternatives such as heated tobacco products. Prime Minister Jacinda Ardern slammed the move as not sincere, noting: “I think if they (Philip Morris) are really focused on reducing harm, ending the premature deaths caused by smoking then just not selling cigarettes would make a huge contribution.”

In a similar move, JUUL is reported to be targeting native American communities in the USA. The company (in which tobacco giant Altria—parent company of Philip Morris USA—recently purchased a 35% stake) has been sending representatives to communities to give out free samples and starter kits. Similar to the PMI approach in New Zealand, JUUL is offering the strategies as part of a smoking cessation/switching programme, with a ‘full time programme director’ offered to the tribe at no cost.

There is a striking coherence to these targeted strategies, which also aligns with the activities and rhetoric of the PMI-funded Foundation for a Smoke Free World (FSFW). In 2018, FSFW provided a US$1 million grant that created a Centre for Research Excellence: Indigenous Sovereignty and Smoking, led by a Māori researcher and prominent advocate for vaping and other alternative products. Although based in Aotearoa/New Zealand, the Centre is intended to be global in scope.

In May this year, an editorial by 13 leading Indigenous health researchers and leaders from New Zealand, Canada, the USA, Australia and Papua New Guinea was published in Tobacco Control, firmly rejecting tobacco industry strategies and funding, no matter how these are packaged. The authors noted that for indigenous peoples for whom tobacco has always been part of their culture ‘the modification, transformation and commercialisation of the nicotiana tobacco plant belittles and disrespects something which is held sacred’ and ‘tobacco industry–funded research activities can be seen as a form of contemporary colonisation’. They concluded: ‘Indigenous peoples should not accept tobacco industry funding. Whether it is explicit or implicit, the tobacco industry will use the Foundation to meet its agenda which is in stark contrast to the health and well-being agendas of Indigenous peoples. Indigenous communities and the public health sector must act now to resist co-optation of Indigenous culture, seek a genuine end to nicotine addiction among our peoples and unify against the industry’ (See: https://tobaccocontrol.bmj.com/content/early/2019/05/10/tobaccocontrol-2018-054792).

World: BAT’s (selective) celebration of world parents’ day

In a shameless public relations strategy, British American Tobacco (BAT) hopped on the Global Day of Parents bandwagon this year, co-opting the day as a way to project itself as a family friendly employer. The Global Day of Parents, celebrated on 1 June each year, is proclaimed by the United Nations as ‘an opportunity to appreciate all parents in all parts of the world for their selfless commitment to children and their lifelong sacrifice towards nurturing this relationship.’ The UN also makes reference to the Sustainable Development Goals (SDGs) and their focus on ending poverty, promoting shared economic prosperity, social development and people’s well-being while protecting the environment.

The tobacco industry repeatedly attempts to use corporate social responsibility initiatives to position itself as a contributor to achieving the SDGs. In reality, the industry and its products create and exacerbate poverty and inequality, hamper social development, harm well-being and contribute to environmental degradation. Bearing all this in mind, it was a crazy audacious move to try and co-opt Global Day of Parents for their own ends. So, how did they approach it?

According to their website, proud parents in their UK headquarters were asked ‘What does being a parent mean to you?’. Interestingly, there was no mention of whether these ‘proud parents’ consume the products of their employer—or whether they dreamed of their child/ren using BAT products when they grow up. Of course, readers familiar with the tobacco industry would be well aware that tobacco industry employees tend to see their products as being for ‘other people’.

The winning entries were then given a professional family photo shoot and showcased on the BAT website with lots of fluffy, feel good comments about ‘making the world a better place’, ‘realising the meaning of life’ and knowing your child ‘can do anything’. Touching indeed—as long as you don’t think about all the parents taken from their children too soon because they were a loyal consumer of BAT products, or the tobacco farmers caught in poverty, producing a crop that harms them and their children for the profit of shareholders and comfortably middle-class employees in high-income countries like Britain.

Switzerland: PMI strikes short-lived PR deal with government

Figure 1

Former UN Development Programme Administrator and New Zealand Prime Minister Helen Clark’s tweet in response to Michael Møller’s departing memo urging a rethink on the UN policy of non-engagement with the tobacco industry. The tweet was retweeted by WHO Director General Tedros Adhanom Ghebreyesus. Source: Twitter/Helen Clark.

Figure 2

A mock picture showing Switzerland as the ashtray of Europe. Created by: Pascal Diethelm.

As described in the editorial for this edition, behind the polite veneer of political neutrality, Switzerland is an epicentre for global tobacco industry lobbying, helped by the fact that it is home to the global headquarters of three of the four largest transnational tobacco companies, and several cigarette factories. Together with the fact that WHO headquarters are also in Switzerland, it provides fertile ground for the industry to exert global influence.

Shortly after the eyebrow-raising memo by outgoing UN office head Michael Møller urging a reconsideration of UN non-engagement with the tobacco industry (the language of which echoed PMI rhetoric), the Swiss foreign minister was under scrutiny for a new sponsorship deal between PMI and the Swiss government. Reported to be worth 1.8 million Swiss francs (approximately US$1.815 million), the sponsorship was to contribute to costs for Switzerland’s pavilion and presence at Expo 2020, to be held in Dubai. The Swiss Foreign Ministry had stated that it was trying to save public money by seeking sponsorships to cover 50% of the cost of its Expo presence.

PMI’s largest research and development centre is located in the Swiss city of Lausanne. A company spokesperson said the company saw an opportunity to ‘highlight science and innovation’, and that it would not promote cigarettes at the Expo but a smoke-free product—presumably its heated tobacco product IQOS. The sponsorship deal would have given PMI the ‘association of their image with that of official Switzerland’. It also provided the right to use the official logo of the Swiss pavilion for their own communications, public relations and advertising, logo presence on billboards and screens, and quotes for the use of the event lounge for PMI events.

Switzerland is one of a handful of countries that has not ratified the FCTC (an omission which is reflected in its manifestly inadequate tobacco control policies), and is therefore not bound by its obligations. The deal nonetheless raised concerns both within Switzerland and at WHO headquarters. The WHO stated that the deal likely breached a 2011 memorandum of understanding it signed with the Bureau International des Expositions (BIE), which addresses public health issues linked to global events, and includes a ban on tobacco advertising, sales, promotion and sponsorship. Critics within Switzerland included the Federal Office of Public Health, the National Tobacco Prevention Working Group, the Swiss School of Public Health and several politicians.

Tobacco companies often find that ministers with portfolio responsibilities outside health are receptive to their overtures. However, this sponsorship decision was particularly disappointing, given that the Swiss foreign minister Dr Ignazio Cassis is a medical doctor who practised for over a decade until 2008, holds a Master of Public Health and was the vice president of the Swiss Medical Association from 2008 to 2012. Unlike some non-health government ministers, he could hardly plead ignorance about the impact of tobacco, nor the tactics of the tobacco industry. Cassis was reported to have viewed the deal with ‘scepticism’ and believed the arrangement could undermine the intended goal of Switzerland’s presence at the event, to project a positive image of the country.

At the time of going to press, there were reports that the deal had been scrapped following continued criticism. The fact that such a deal could have been agreed to by the Swiss government in the first place is a damning indictment of its willingness to embrace the tobacco industry.

France: Cannes festival puts Philip Morris on ‘good track’

Being featured as an organisation on the ‘Good Track’ at an internationally known high profile festival, and sharing the stage with organisations such as UN Women, Greenpeace and the child-focused US non-profit Sesame Workshop is a dream opportunity for an organisation trying to find new ways to present itself as a public health stakeholder, and gain a seat at the global policy-making table. PMI made much of it when it was featured on the ‘Good Track’ programme at the Cannes Lions Festival in June.

The purpose of the ‘Good Track’ is to highlight life-changing work and initiatives which make the world a better place by focusing on brands, talent and industry leaders who positively impact society. As a company which markets products that harm both people and the environment, and whose business model is based on building a customer base for an addictive substance from as young as possible, the inclusion of PMI in the programme is ”puzzling at best and deeply troubling at worst“, according to Sandra Mullins of global non-profit health organisation Vital Strategies. She also stated: “Their appearance at Cannes is a calculated effort by a deservedly maligned industry to remain relevant and continue to thrive. They are positioning their latest marketing strategy as a conscience-driven, reputation-refurbishing mission of working towards a ‘smoke free world’…despite the fact that they will produce 800 billion cigarettes in 2019.”

The event proved to be another platform for PMI to attempt to convince the world it has transformed and should be considered part of the solution, rather than a major contributor to the global tobacco problem. It paid the actor Rose McGowan and marketing entrepreneur Bonin Bough to attend an ‘Open Mic’ session it hosted with a range of other organisations and people, many featured on the PMI website with quotes well aligned with PMI’s narrative.

It also focused on repositioning its heated tobacco products and vaping products as a primary strategy for ending smoking, rather than one small (potential) component of a full and comprehensive tobacco control approach. As detailed in the final article below, the most recent WHO report on the tobacco epidemic is a testament to the as-yet unrealised potential of full implementation of evidence-based measures to both reduce smoking uptake and encourage increased quitting among smokers. A recent supplement published by Tobacco Control also showed the importance of the FCTC and the ongoing challenges of tobacco industry efforts to derail effective tobacco control policies (https://tobaccocontrol.bmj.com/content/28/Suppl_2). Meanwhile, PMI continues to oppose the implementation of such measures, while aggressively marketing and selling cigarettes in countries such as Indonesia.

Of course, full implementation of the complete suite of evidence-based measures to reduce tobacco use globally would be a fatal blow to commercial tobacco. However, if the tobacco industry dies a slow, protracted death because sales avenues for its main product are strangled, and there is insufficient opportunity for its newer products to prosper, that is frankly no concern of public health. Throughout history, decent, legitimate businesses and industries have died out; many of which provided a net benefit to humanity, in stark contrast to the tobacco industry.

While PMI’s promotions such as its ‘Unsmoke’ campaign do note that the best option for smokers is to quit smoking and nicotine altogether, in business-focused media, the company’s narrow commercial interests are more nakedly on display. An article published through Business Wire about PMI’s involvement in the festival states: ‘Philip Morris International (PMI) is leading a transformation in the tobacco industry to create a smoke-free future and ultimately replace cigarettes with smoke-free products to the benefit of adults who would otherwise continue to smoke, society, the company and its shareholders’. Note the absence of any pretence that the goal is for people to quit completely.

China: Tobacco and Belt and Road Initiative—the new ‘Go Global’?

China National Tobacco Company (CNTC) is the world’s largest manufacturer of cigarettes, accounting for a third of the total global output. The powerful state-owned tobacco monopoly, previously focused on the vast domestic market with 350 million smokers, has been nurturing growing global ambitions since the early 2000s. Faced by an increasingly saturated domestic market and the potential for stricter tobacco control regulation, CNTC adopted the central government’s ‘Go Global’ strategy in 2003, to replace lost domestic revenue with exports. It has since expanded its global reach to 20 countries, operating through 34 offshore facilities, which include sales offices, manufacture plants and specialised procurement companies.

The One Belt One Road strategy, also known as the Belt and Road Initiative (BRI), is President Xi Jinping’s signature foreign policy launched in 2013. The ambitious infrastructure initiative is comprised of two parts: overland Silk Road Economic Belt, linking western China to Europe through Central Asia and the Middle East along the ancient trading route; and the Maritime Silk Road, connecting coastal China to Europe through South-East Asia and East Africa. To date, more than 125 countries have joined and more are expected to sign up. The BRI mainly focuses on infrastructure development (such as rail, roads and ports), trade, and culture and tourism. As with other government initiatives, state-owned enterprises will be expected to be ‘dragon heads’ and lead by example.

CNTC, as a key state-owned enterprise, has indicated willingness to be a leader in the initiative back in 2015, when then-director Ling Chengxing emphasised the importance of using the opportunity of ‘the national implementation of BRI…to accelerate industry’s ‘Go global’ development’. In 2017, BRI was officially adopted by the Chinese tobacco industry, as the State Tobacco Monopoly Administration issued a ‘Work plan on the tobacco industry participating in One Belt One Road to implement ‘Go Global’ development’.

Specifically, the work plan calls for market expansion in BRI countries and support for the construction of offshore production facilities. BRI countries, especially those in Central Asia and the Middle East, are seen as particularly attractive for market expansion, as they remain relatively underserved and not yet dominated by the transnational tobacco companies. With these countries accounting for 54.1% of global tobacco sales, the potential for growth is enormous. In line with past statements, CNTC anticipates the introduction of its products via Chinese workers, who will no doubt be recruited to work on infrastructure projects, and an expected influx of Chinese tourists, especially as China flexes its soft power by negotiating more favourable visa requirements. According to industry statements, CNTC’s market expansion is now focused on BRI’s emerging and growth markets, and includes monitoring for investment and joint venture opportunities, and market development

Domestic smoking rates in China declined for the first time in decades following 2015 tax increases, fueling CNTC’s international push. The unprecedented public listing of CNTC’s international arm—China Tobacco International—on the Hong Kong stock exchange in June 2019, is the strongest indicator to date of the industry’s globalisation ambitions. The move is expected to fund CNTC’s overseas ventures, as it aggressively expands into unknown markets. It appears that China’s push for political and economic dominance in the region via the BRI may need to come with a health warning.

Jennifer Fang is a Project Administrator and Research Fellow at the Global Tobacco Control Research Programme, Faculty of Health Sciences, Simon Fraser University, Canada. Her research mainly focuses on the Asian tobacco industries, with an emphasis on China.

Jennifer Fang

Simon Fraser University, Canada

jennifer_fang@sfu.ca

World: WHO tobacco report highlights both progress and gaps

Figure 3

A graph from the seventh WHO global report on the tobacco epidemic, showing the growth in the number of countries and global population covered by at least one MPOWER measure at the highest level of achievement.

Figure 4

A graph showing the increase in selected tobacco control policies since 2007.

The seventh WHO global report on the tobacco epidemic, launched in Rio de Janeiro, Brazil on 26 July contained mixed news. While significant progress has been achieved, implementation of MPOWER measures at the highest level of achievement remains the exception rather than the norm. Brazil is only the second country, after Turkey, to implement all MPOWER measures at the highest level.

The focus of this latest WHO report is on helping tobacco users to quit. In 2007, only 400 million people globally were covered by this measure; in 2018 it had increased to 2.4 billion. While 171 countries offer cessation services, only 23 offer support at the highest level. Of the remainder, 116 provide fully or partially funded services at some or most health facilities. Thirty-two countries offer smoking cessation services, but do not cover the cost.

Over half the world’s population (3.9 billion people living in 91 countries) are covered by graphic health warnings with all recommended features, making it the MPOWER measure with the highest global population coverage and most countries covered. Despite having a high impact and being cost-effective for governments, taxation remains the measure with the least coverage of the world’s population. Although it has increased by 7% since 2007, only 14% of the global population is covered. Since the previous report, 10 countries have increased taxes to at least 75% of the retail price, in line with best practice.

There has also been a significant increase in smoke-free environments from 7% to 19% of the world’s population between 2007 and 2018, including in several low-income and middle-income countries. Encouragingly, 17 of the world’s 34 low-income countries have implemented at least one MPOWER measure to the highest level. However, 59 countries have yet to adopt a single MPOWER measure at the highest level of achievement, of which 49 are low-income or middle-income countries.

Given the forces lined up against effective implementation of the FCTC and MPOWER measures, the progress in the last decade has been remarkable. However, there is still much unrealised potential for these measures—further highlighting that, contrary to tobacco industry rhetoric, alternative products such as e-cigarettes have—at best—a minor role to play in ending the tobacco epidemic.

The report can be accessed at: https://www.who.int/news-room/detail/26-07-2019-who-launches-new-report-on-the-global-tobacco-epidemic.

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Footnotes

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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