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Worldwide news and comment
  1. Marita Hefler
  1. Wellbeing & Preventable Chronic Disease, Menzies School of Health Research, Casuarina, Northern Territory, 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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USA: Setting the sun on Big Tobacco

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

Figure 1

As Brexit uncertainty grips the UK, the country’s Treasury Department announces how UK citizens will be able to avoid tax in the event of a no-deal exit. Source: Twitter/Martin McKee.

Figure 2

ASH Executive Director Laurent Huber (L) with Beverly Hills Mayor John Mirisch (R) holding the Sunset Award for Courage in Public Health that was awarded to the City of Beverly Hills at the US National Conference on Tobacco or Health in August 2019. Credit: ASH.

The National Conference on Tobacco or Health (NCTOH) was held in Minneapolis, USA from August 27–29, 2019. It was an exciting week for public health experts, advocates, researchers, and policymakers to network and learn from each other, in turn strengthening public health policies and campaigns across the U.S.

NCTOH 2019 served as the launching pad for U.S. advocacy on Project Sunset, a global effort to phase-out the sale of commercial tobacco. During the Opening Plenary, U.S. Surgeon General Jerome Adams spoke about the urgency of the tobacco epidemic and encouraged cities and states to get creative when seeking to end it. He noted that Beverly Hills’ Mayor John Mirisch was in attendance and had recently worked to pass an ordinance to end the sale of most tobacco products in his city, making Beverly Hills the first U.S. city to adopt such an innovative and life-saving policy.

Conference organisers gave Project Sunset a subplenary on the opening day. Speakers included Ruth Malone of the University of California, San Francisco, Carol McGruder of the African American Tobacco Control Leadership Council, Joelle Lester of the Public Health Law Centre, and Chris Bostic of Action on Smoking and Health, with Andrea Mowery moderating. The speakers covered key topics such as health inequities, legal challenges, advocacy, and public outreach.

Following the subplenary presentations, ASH Executive Director Laurent Huber presented Mayor Mirisch with the first-ever Sunset Award for Courage in Public Health. Beverly Hills is leading the way with their tobacco sales ban, and other cities will no doubt soon follow their lead.

Throughout the conference, Action on Smoking and Health ran the Project Sunset booth, distributing advocacy materials, answering questions, and gathering support. The Endgame subplenary speakers all spoke at the booth as well, diving in deeper on key topics with attendees who wanted to learn more about how to prepare to phase out the sale of cigarettes in their communities.

Project Sunset turns Philip Morris USA’s own Project Sunrise – a scheme to renormalize smoking – on its head. It’s time to respond to cigarette sales in a way that is proportionate to the harm they cause; that stronger response started at the U.S. NCTOH this year.

An earlier version of this article was published on the Tobacco Control website at https://blogs.bmj.com/tc/2019/09/23/usa-setting-the-sun-on-big-tobacco/

Megan Arendt

ASH >Action on Smoking & Health

arendtm@ash.org

World: PMI-funded FSFW adding insult to injury

Despite 7 million deaths annually and counting, tobacco control worldwide continues to be seriously underfunded as a public health priority. This funding gap is especially acute in low-income countries and among certain historically disadvantaged populations. It is into this space that the Philip Morris International (PMI) financed Foundation for a Smokefree World (FSFW) has stepped in to flash the cash in a search for allies. In 2018, the Foundation provided funds to create the Centre for Research Excellence: Indigenous Sovereignty and Smoking in New Zealand. Indigenous peoples in settler countries, such as the Māori population in New Zealand, have higher smoking rates and, consequently, disproportionate levels of tobacco-related disease and deaths. The appropriateness of accepting tobacco industry funding, to address a problem created and sustained by that same industry, has been deeply controversial.

It is in a similar context that the Foundation has gone knocking in Malawi. The country’s economy is the most tobacco leaf-dependent in the world. While the government accepts the need to diversify, many development agencies have declined to engage with farmers due to their association with the tobacco industry. This presents an opportunity for the FSFW to step in with funding to “address the agricultural impact of smoking cessation.” Its engagement in Malawi includes plans to establish a Centre for Agricultural Transformation and a “signature” regional conference to “inform a strategy and action plan to drive economic diversification.” In November 2018, one of the authors conducted interviews with policy makers, farmers unions and ex-tobacco industry employees in Malawi to understand the role of China in Malawi’s tobacco industry. We found positive interest in Malawi in the planned centre’s capacity to “assist the country to diversify”. Knowledge of its PMI funding was not mentioned by interviewees. The centre has the potential to embed FSFW (and through it, PMI) within policy making networks, and create a position of ongoing influence in the country.

A further strategic target of the FSFW’s largesse is China, where the official annual number of tobacco-related deaths has now reached one million. We conducted interviews with tobacco control experts in China in July 2016 to understand local perceptions of the tobacco industry’s corporate social responsibility projects and found the longstanding shortfall in tobacco control resources was gravely apparent, with funding largely coming from external organisations. In 2019, the FSFW Board Governance Committee recommended the appointment of “a director with expertise in China.” Anticipating challenges in navigating China’s complex policy landscape, a US$1.3 million budget was allocated to engage APCO Worldwide to “establish the necessary framework for the Foundation, including governance, infrastructure, staffing and support pieces.” It enhances the industry’s presence in Asia, where the vast majority of the world’s smokers reside. In the absence of institutional public statements against engaging with the PMI-funded Foundation in China, the entry of a controversial funder with deep pockets would be a major public health setback.

The three cases above suggest a pattern to how the FSFW is seeking footholds with underserved populations. Recipients welcome new resources to address longstanding needs. For PMI, this engagement strategy casts its FSFW in hero mode, undermining global tobacco control solidarity against the industry while sustaining its business plan to globally dominate both the traditional and alternative nicotine product markets.

This article, with additional references, was first published on the Tobacco Control website at https://blogs.bmj.com/tc/2019/09/26/world-pmi-funded-foundation-for-a-smoke-free-world -adding-insult-to-injury/

Jennifer Fang,

Kelley Lee

Simon Fraser University, Canada

jennifer_fang@sfu.ca

Canada: government releases consumer research on vaping & tobacco

Figure 3

Vaping promotions at an Esso gas station near Ottawa, August 2019. Credit: Cynthia Callard, Physicians for a Smoke-Free Canada.

Figure 4

Canadian consumer research evaluated the response to warnings printed on cigarettes. Credit: Cynthia Callard, Physicians for a Smoke-Free Canada.

The Canadian nicotine market was transformed virtually overnight after the government of Canada legalised the sale of vaping products in May 2018.

Previously, Canadians were able to buy unregulated vaping devices and liquids online or in a modest number of illegally-operating shopfronts. Their choice of device, however, was mostly limited to the clunky tank systems supplied by small manufacturers willing to sell on the grey market. Advertising for vaping products was seen only in the broadcasts and media that spilled over from the United States.

After market liberalisation, Canadians could buy their (not yet) regulated devices and liquids in almost every corner store. Their choice of device was expanded to include the sleek and inexpensive systems sold by large multinational manufacturers, such as JUUL, BAT, Japan Tobacco, and Imperial Brands. Pod systems selling high concentrations of nicotine salts became the norm (JUUL boasts of a 79% market share). In many regions, advertising for vaping products has become pervasive: the cigarette power walls that were removed only a decade ago have now been replaced with vaping advertising.

These changes to the vaping market resulted from the government’s decision in 2017 to adopt a “harm reduction” approach to smoking. The new law was structured to “strike a balance between protecting youth from inducement to nicotine and tobacco use, while allowing adult smokers to legally access vaping products as a less harmful alternative to tobacco.”

With this decision, and the adoption of the Tobacco and Vaping Products Act, Canadians were abruptly enrolled in a natural experiment on the impact of a liberalised nicotine market on their health behaviours. Canadians have mixed views towards novel tobacco control measures, but many had supported greatly expanding access to vaping products.

Assessment of the results of this experiment has been challenged by the absence of early data on the impact on nicotine use. The health surveillance systems in place for the first 18 months did not include any indicators on vaping: Canadian Tobacco, Alcohol and Drugs Survey had been suspended in 2017 and its replacement will not be in the field until November 2019.

To address the information gap, Health Canada issued contracts totalling more than USD 1 million to polling firms and other consumer researchers, tasking them with surveying Canadians about vaping. These studies, listed below, probed for information on a wide range of behaviours and attitudes related to nicotine use – why people start, which products they use, what they think of the harms, the flavours they use, whether their friends and families approve, etc.

These studies do not allow us to conclude whether the Canadian vaping experiment has resulted in a net reduction of harm from nicotine use. They do, however, give insight into the minds and motivations of users. When the surveillance system gets up and running, this consumer research can help guide policy adjustments if it appears that the harm reduction balance needs recalibrating.

Had these studies been conducted by university-based researchers, the results would normally find their way into the academic press. Canadian governments do not take this approach, but instead make the findings and data tables available through the federal government’s library of public opinion research – representing a trove of data ready for secondary analysis.

Health Canada’s consumer research also covers traditional tobacco products. In preparation for updating tobacco package warning labels, consumer research was commissioned to test concepts and visuals. One of the studies looked at reactions to warnings printed directly on cigarettes – an idea Health Canada floated last year.

This is an edited version of an article published on the Tobacco Control. The full article with additional links including to the Health Canada research findings and data tables is at https://blogs.bmj.com/tc/2019/09/28/canada-government-releases-consumer-research-on-vaping-and-tobacco/

Cynthia Callard

Physicians for a Smoke-Free Canada

ccallard@smoke-free.ca

Indonesia: Tax rise announcement punishes tobacco companies

Despite the fact that Indonesia is one of the few nations to have not ratified the WHO Framework Convention on Tobacco Control, and its well-justified reputation as a haven for the tobacco industry, there have been some positive moves in recent times. The latest encouraging news was an announcement in September of a plan to raise excise tariffs. Set to take effect from 1 January 2020, the excise will increase by 23% and raise retail prices by 35% on average.

Predictably, the plan was met with the tobacco industry raising its usual bogeyman of illicit tobacco along with apparent hurt feelings that they weren’t warned it was coming (presumably so they could have tried to derail it by behind the scenes lobbying). The finance minister defended the rise, noting the rising numbers of young smokers, particularly among women.

The announcement saw the share prices of the major tobacco companies take a big hit: Indonesian manufacturer Gudang Garam and Philip Morris-controlled HM Sampoerna both fell more than 20%. It was the biggest drop for both companies this century.

Bangladesh: Philip Morris funded FSFW controversy over charity funds

In early August, the Tobacco Industry Watch Team at PROGGA Knowledge for Progress highlighted the case of two highly regarded NGOs accepting grants from the Philip Morris funded Foundation for a Smoke Free World (FSFW). BRAC, an NGO which runs a range of development and health programme, accepted USD64,115 in June to do a project to identify behaviour patterns, risk perception & social factors that discourage TB patients to quit smoking. To its credit, and in line with its well-regarded reputation, BRAC made the decision to return the funds the following month after calls from journalists of Anti-tobacco Media Alliance-ATMA about the issue.

The Child Sight Foundation (CSF) also received a grant worth USD92,620 to undertake a systematic review & situation analysis of smoking & perception about harm reduction among slum dwellers. This is particularly concerning, given the organisation’s focus on vulnerable youth. At the time of writing, CSF had not made a decision to return the funds.

PROGGA praised the stand taken by BRAC, noting it would contribute to building a tobacco-free country as propounded by the Bangladesh government, and encouraged BRAC to adopt a policy of no-collaboration with the tobacco industry to prevent a recurrence of such a situation in the future. It also called on CSF to return its grant, noting the impact of tobacco on the poorest in Bangladesh: “Slum-dwellers are struggling to put food on the table. Money spent on tobacco is money that is taken away from food and other more important basic necessities. We hope this recipient will also reject this harmful partnership with the Foundation and its funder, Philip Morris International.” PROGGA also noted that the government should impose a ban on PMI funded Foundation for a Smoke-Free World activities, as the prime minister is committed to making the country tobacco-free by 2040.

India: government ordinance to ban ENDS with immediate effect

The government of India on 18th September issued a presidential ordinance to stop the sale of all kinds of electronic nicotine delivery systems (ENDS), with immediate effect. The ordinance includes a complete ban on production, manufacturing, import, export, transport, sale (including online sale), distribution or advertising (including online advertising) of e-cigarettes in the country. The government considered that these devices are injurious to health and their proliferation has a negative impact on public health.

With this law, the central government took control of the electronic cigarettes industry (Section 2) and imposed a complete ban on the product, its advertisement (Section 4) and storage (Section 5). The owners of existing stocks of e-cigarettes, at the commencement of the law, will have to voluntarily declare and submit these stocks, without any unnecessary delay, to the nearest police station. The police station authorised officer will thereafter take necessary measures for its disposal as per the law. The officer is also vested with the powers to enter, search and seize products without warrant in case of any suspected violation of the law by any person or place (Section 6).

The penalties for violations of section 4 of the law include 1 year imprisonment or fine of up to Rs. 1 lakh (US$1400) or both for first offence and 3 years’ imprisonment and fine up to Rs. 5 lakh (US$7000) for a subsequent offence (Section 7). Violation of this provision has also been made a cognizable offence (Section 13), that is, a police officer could arrest a violator without an arrest warrant. The storage of ENDS products is punishable with 6 months imprisonment or fine up to Rs 50 000 (US$700) or both (Section 8). Action for violation of the Ordinance can be initiated only on a complaint in writing by the authorised officer (ie, any police officer not below the rank of a sub-inspector or other person so designated by the central or state government) (Section 12). The Ordinance also has a clause (Section 14) to override any conflicting law in force in the country (for example, if ENDS were classified or treated differently under any state or federal law).

This initiative has been under consideration for the last year, but was expedited after a white paper from the Indian Council of Medical Research recommending a complete prohibition on all ENDS in India was released on World No Tobacco Day (31 May). The WHO FCTC Conference of Parties at its seventh session held in India in 2016 also recommended member countries take appropriate steps to protect public health, including prohibiting these products. The ordinance, as recommended by experts and keeping with the earlier ministry of health advisory, includes a ban on e-cigarettes and all forms of ENDS, including heated tobacco products, e-hookah and similar devices.

The initial steps were taken in the first term of the Narendra Modi Government, which issued a detailed advisory to the states in August 2018 against the manufacture, sale and distribution of all forms of ENDS. Keeping with this advisory, eighteen states and union territories (Odisha, Rajasthan, Meghalaya, Maharashtra, Karnataka, Kerala, Bihar, Uttar Pradesh, Jammu & Kashmir, Mizoram, Himachal Pradesh, Tamil Nadu, Puducherry, Jharkhand, Punjab, Gujarat, Nagaland, Haryana) had already notified and implemented the ban declaring nicotine as an unapproved drug under the existing Drugs and Cosmetics Acts and a poisonous substance under the Poisons Act within their respective jurisdictions. Several other enforcement agencies including the Central Board of Indirect Taxes and Customs (Anti-Smuggling Unit) and the Drug Controller General of India also directed all their officials to ensure compliance with the advisory.

Piush Ahluwalia, an ENDS user, challenged the advisory before the Delhi High Court which observed that the advisory was not binding in nature and the states were free to take an informed view on its implementation. After this order of the Delhi High Court, the Ministry of Health and Family Welfare started moving to legislate a comprehensive ban on ENDS in the country. The government planned to implement the ban on ENDS as part of the first ‘100 days” of the second term of the Modi Government as an unapproved drug under the Drugs and Cosmetics Act, 1940. However, it finally decided to take the emergency law making route and implement the ban on ENDS by issuing a presidential ordinance.

The tobacco and vaping industries responded by suggesting that it will result in severe loss of revenue for tobacco farmers. This led to the Prime Minister constituting an empowered group of ministers in September 2019, led by Finance Minister Ms Nirmala Sitharaman, to review the health ministry’s proposal. At a cabinet meeting on 18 September, the Ministry of Health’s proposal to issue an ordinance was accepted. This cleared the way for promulgation of the Prohibition of Electronic Cigarettes (Production, Manufacture, Import, Export, Transport, Sale, Distribution, Storage and Advertisement) Ordinance, 2019 on the same day by the President of India. The enforcement of the law has already begun across India with state governments issuing public notices to both inform the public and to ensure compliance with the law.

This law also blocked Juul’s plans to launch its e-cigarette in India, after the company had hired several senior executives in recent months, as well as thwarting Philip Morris, which had plans to launch its IQOS heated tobacco device there.

The ordinance has already been challenged by two e-cigarette importers, Plume Vapour and Woke Vapours, before the Calcutta High Court, Kolkata. However, the Government of India is committed to implement the ban in its present form. The Prime Minister of India highlighted his Government’s decision to ban e-cigarettes to deal with the worrisome craze of e-cigarettes among youth during his speech at the UN on September 23, 2019.

With this ordinance, India joins Brazil, Thailand, Australia and others in banning ENDS to keep these products out of the country.

Amit Yadav

Stanton Glantz

University of California, San Francisco, USA

Amit.Yadav@ucsf.edu

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Footnotes

  • Twitter @m_hef

  • 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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