Asia-Pacific: a tobacco control pioneer

Asia is a tobacco control pioneer: in 1970 Singapore became the first country in the world to introduce national smoke-free legislation10 followed by the first (at the time) comprehensive bans on tobacco advertising in 1971.11 The earliest significant research on secondhand smoke came from Japan: Hirayama’s 1981 cohort study on passive smoking among 91 000 non-smoking married Japanese women, showing that wives of heavy smokers had a higher risk of lung cancer than wives of non-smokers.12 The tobacco industry tried unsuccessfully to discredit Hirayama’s paper.13 14 The government-funded Hong Kong Council on Smoking and Health was established in 1987,15 the same year that Hong Kong became the first jurisdiction in the world to ban manufacture, importation and sale of smokeless tobacco products.16 In 1991, Singapore was also the first country to ban incoming duty-free cigarettes.4

Another global first was the Philippines’ Joint Memorandum Circular on the ‘Protection of the bureaucracy against tobacco industry interference’ issued in 2010 in compliance with WHO Framework Convention on Tobacco Control (FCTC) Article 5.3.17

Back to the past to understand the present

In the 1980s, the US Trade Representative (USTR) threatened various Asian jurisdictions with trade sanctions unless they opened their markets to American cigarettes.18 Japan, the Republic of Korea and Taiwan bowed to US pressure. While the Thai market eventually had to open to US cigarettes, Thailand successfully retained the right to ban advertising of both national and international brands.19 A 1996 study from the National Bureau of Economic Research showed that per capita cigarette consumption in the four jurisdictions was nearly 10% higher than it would have been if markets had stayed closed to American cigarettes.20

The USTR challenge galvanised Asia’s tobacco control efforts and led to the early realisation that tobacco control involved politics, legislation, economics and trade. It also showed very clearly that the tobacco industry was the vector of this epidemic, and only by tackling the industry, its allies and its commercial and political supporters, could tobacco control be successful.4

Building upon this over the last 30 years, the WHO’s Western Pacific Region is the only WHO region where all countries are Parties to the WHO FCTC.21 Some countries like Singapore have very advanced tobacco policies that are arguably on par or comparable with those in other regions with a high FCTC implementation score.

Asia has shown that action to reduce the tobacco epidemic is not the prerogative of western high-income countries, and that Asian nations—including low/middle-income countries—can grasp the political nettle of tobacco control and act successfully.

Key challenges

While the region consists of many dynamic countries with unique sets of characteristics and challenges, obstacles to tobacco control in Asia are similar to those around the world. Many of these obstacles lie with governments. They include lack of political commitment to tobacco control, inequalities within societies, more resources going to curative medicine than preventive health; a focus on short-term tobacco tax revenue but not the overall cost of tobacco to the government, employers and individual smokers; misperceived and incorrect concerns about economic losses if tobacco control measures are implemented; and a preoccupation with other events, crises or diseases that cause far fewer deaths than tobacco. Although spurred forward by entry into force of the WHO FCTC, policy progress has been slow in many countries, and no Asia-Pacific country has yet fully implemented the WHO FCTC22 explicitly mentioned as a means to achieve the UN Sustainable Development Goals.23

Looming equally large is the obstructionist tobacco industry. Internal industry documents,24 the Tobacco Industry Interference Index,25 26 and Stopping Tobacco Organisations and Products (STOP)27 all document how the industry, its allies and front groups ignore or misrepresent the evidence; promote tobacco use with advertising, promotion and corporate sponsorship, in the process building relationships with government, media, and other organisations; challenge tobacco control legislation and tax increases28 29; attack individuals, organisations and the WHO30; and mount legal challenges against governments.31–34 The companies are also involved with smuggling their own products, which opened up new markets previously dominated by government monopolies and which flood markets with cheaper cigarettes, making them more affordable to children.35 36 They even secretly employed scientists in the infamous ‘Asian Whitecoat Project’ to work undercover and slant the scientific data on secondhand smoke.37–40 In some Asian countries, tobacco companies promote a ‘revolving door’ culture by recruiting former senior government finance and trade officials.41

Over the last 30 years, many state tobacco monopolies in Asia have morphed into behaviour previously exhibited only by private transnational companies.42 The Chinese monopoly has also embarked on major global expansion, with offices and factories around the world, using the Belt and Road Initiative, and is becoming a major international player.43

Globally, as part of its broader tactic of corporate social responsibility (CSR), the industry has exploited the COVID-19 pandemic by donating medical supplies and equipment to try to shift its image from harmful industry to helpful health partner, to make and maximise contact with policymakers,44–46 and to obstruct tobacco control measures.47 Such tactics have been recorded in Indonesia, Malaysia, Philippines and Vietnam. Philip Morris Malaysia donated personal protective equipment to the Ministry of Health through a high-profile foundation,48 while the government is still deliberating e-cigarette policy. In the Philippines, as the industry stepped up its CSR, a bill to reward the business sector for CSR activities is pending in Congress,49 which if passed, will undermine the Joint Memorandum Circular protecting the bureaucracy from industry interference.

The Philip Morris-funded Foundation for a Smoke-Free World (FSFW) has distributed grants throughout Asia, buying influence and goodwill and funding front groups that attack tobacco control advocates and their work.50 The Southeast Asia Tobacco Control Alliance has denounced the FSFW, urging governments, universities and health institutions to reject partnerships with the foundation, deeming it a tool to sabotage global tobacco control.51

What is most needed in the Asia-Pacific region?

While the region varies considerably regarding population, gross domestic product, political systems and industry structure, there are more similarities than differences: harms caused, obstacles faced—especially industry behaviour—and tobacco control actions needed. Most needed, as elsewhere, are long-term government plans and targets for tobacco control that are integrated into national sustainable development plans and that are aimed at achieving a tobacco endgame as soon as possible. This would need adequate and sustainable resources for full implementation of the WHO FCTC (both demand and supply reduction measures), underpinned by Article 5.3, which applies to all three branches of government—the executive, the legislative and the judiciary. Civil servants in all branches of government (including embassies and trade commissions) require transparency and accountability in all dealings with the industry. Among best practice examples of civil service codes of conduct for compliance with WHO FCTC Article 5.3 and for protecting national public health policy against tobacco industry interference is the Philippines.52 Constant vigilance and exposure of tobacco industry tactics, as done by the global tobacco industry watchdog, STOP27 and regularly published in the Tobacco Industry Interference Indexes25 including the dedicated Asian edition,26 need to continue and even be led by governments.

There is a continual need to pass and enforce legislation that fully denormalises the tobacco industry, such as standardised tobacco packaging with large pictorial warnings, national bans on smoking in public places and workplaces, comprehensive bans on tobacco advertising, promotion and sponsorship including CSR, prohibiting flavoured tobacco products, and progressive restrictions on retail access to tobacco products, which would include licensing tobacco retailers and limiting their number and locations, raising the minimum legal age of sale to at least 21 years old, and eventually phasing out commercial sales of tobacco products. No jurisdiction has yet reached the highest level of achievement with all categories of WHO MPOWER, as outlined in table 1.

Countries with large numbers of tobacco farmers and workers, such as China and Indonesia,53 should seriously enact policies and implement programmes that help them shift to economically viable alternative livelihoods to lift them out of poverty and industry exploitation.

Tobacco companies should pay for the damage of their current and future products. Governments should hold tobacco companies liable (WHO FCTC Article 19) for healthcare costs, harm to victims, corruption, illicit trade, environmental damage, food insecurity, child labour and other human rights violations, and more that are caused by their products and by industry tactics.54