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A “Frank Statement” for the 21st Century?

19 Sep, 17 | by Marita Hefler, News Editor

Ruth E. Malone, Simon Chapman, Prakash C. Gupta, Rima Nakkash, Tih Ntiabang, Eduardo Bianco, Yussuf Saloojee, Prakit Vathesatogkit, Laurent Huber, Chris Bostic, Pascal Diethelm, Cynthia Callard, Neil Collishaw, Anna B. Gilmore

The surprise announcement by the former head of the World Health Organization’s Tobacco Free Initiative, Derek Yach, that he would head a newly-established organization called the “Foundation for a Smoke-free World” to “accelerate the end of smoking” was met with gut-punched disappointment by those who have worked for decades to achieve that goal. Unmoved by a soft-focus video featuring Yach looking pensively off into the distance from a high-level balcony while smokers at ground level stubbed out Marlboros and discussed how hard it was to quit, leading tobacco control organizations were shocked to hear that the new organization was funded with a $1 billion, twelve-year commitment from tobacco company Philip Morris International (PMI). PMI, which has been working for decades to rebrand itself as a “socially responsible” company while continuing to promote sales of its top-branded Marlboro cigarettes and oppose policies that would genuinely reduce their use, clearly believes this investment will further its “harm reduction” agenda, led by its new heat-not-burn product, IQOS. But don’t worry, the Foundation assures everyone that “PMI and the tobacco industry are precluded from having any influence over how the Foundation spends its funds or focuses its activities.”

Except that is what a broad range of industry front groups, sometimes headed by respected and even well-intentioned leaders, have been saying since the “Frank Statement” of  1954. The long and sordid history of the industry’s funding of “research,” a major part of the mission of this new foundation, is replete with exactly this sort of blithe reassurance, as Yach himself pointed out in an earlier time. In reality, nothing has changed. The “research” really isn’t the point anyway. The mere fact of having landed Yach is a major public relations coup for PMI that will be used to do more of what the industry always does: create doubt, contribute further to existing disputes within the global tobacco control movement, shore up its own competitive position, and go on pushing its cigarettes as long as it possibly can.

In the video, Yach invites “everyone” to join the “movement” this new organization is starting – implicitly dismissing the past 40 years of tobacco control activism and advocacy and 60 years of tobacco industry lies and duplicity. Leaders of active existing civil society coalitions like the Framework Convention Alliance and the Noncommunicable Disease Alliance were blindsided. Contrary to the video’s claim, there is no shortage of “fresh thinking” in the already-vibrant, already-existing global movement to end the tobacco epidemic. There are many great “endgame”-furthering ideas now being actively debated, studied, and tried out: the primary obstacle to implementing them is the tobacco industry.

PMI  hasn’t stopped opposing the policies that would reduce tobacco use, has it? No: recently leaked documents  show that PMI continues to actively oppose any policy that could genuinely reduce tobacco use. Countries around the world identify the tobacco industry as the single biggest barrier to progress in implementing such tobacco control policies. This “new” initiative is just more of the same lipstick on the industry pig, but in a way it’s far worse this time: by using a formerly high profile WHO leader as a spokesperson, PMI can also accelerate its longstanding ambition to splinter the tobacco control movement.

It’s also not true, as the video suggests, that tobacco control efforts have “plateaued.” Cigarette consumption is declining and since 2003, more than 180 countries have become parties to the World Health Organization Framework Convention on Tobacco Control (FCTC), committing themselves to implement effective policy measures and building public support for ending the epidemic. PMI knows this, hence its ongoing, covert and overt efforts to stymie the FCTC. For example, at the last Conference of the Parties, the meetings where implementation of the treaty is discussed, tobacco farmers organized by PMI demonstrated outside the venue and PMI representatives met secretly with delegates to the meeting.

The company hasn’t announced it is going to stop promoting cigarettes to kids in Africa and Asia, has it? No: in fact, it’s developing “stronger” products for some markets, and  continuing to aggressively promote Marlboro cigarettes to the young through campaigns like “Be Marlboro”(see also here and here). Despite decades of developing and then abandoning so-called “reduced harm” products, cigarettes remain PMI’s biggest moneymaker, dwarfing anything else. Only the profoundly naïve will believe that PMI is not solely promoting its self-interest in supporting this new “foundation”.

In fact, the announcement came the day after a huge win for tobacco control: the exclusion of  tobacco companies (as well as makers of cluster bombs and some other unsavory actors) from membership in the United Nations Global Compact, due to their  incompatibility with responsible business principles. Tobacco control leaders across the globe are convincing governments to protect health policymaking from tobacco industry influence, in line with Article 5.3 of the FCTC. PMI’s response is a new industry sponsored entity, eager to work with governments. From its inception, this organization will constitute a challenge for Article 5.3 implementation.

The timing of the announcement was interesting in another way: just the day before, a new global health initiative led by former US Centers for Disease Control head Tom Frieden was announced, with $225 million in funding from Bloomberg Philanthropies, the Chan Zuckerberg Initiative and the Bill & Melinda Gates Foundation. While this initiative does not focus solely on tobacco, these funders know how much tobacco contributes to disease and death worldwide. They are also funders who have unequivocally taken positions supporting the strong policy measures that work.

What is required to end smoking isn’t helping the world’s leading cigarette manufacturer in its ongoing image makeover while it continues to try to derail the significant public health progress made to date. What is required is leaders who have the humility to work with the movement and policymakers with the backbones of steel needed to stand up to the industry to enact and implement strong tobacco control measures, including high taxes, smokefree laws, effective media campaigns to denormalize both smoking and tobacco companies, and marketing, packaging and retailing regulations to make these deadly products less ubiquitous. The global movement public health activists built over decades of toiling in the trenches must stand together and not allow PMI to buy more time by executing a 21st century version of the  “Frank Statement.”

The authors would like to thank Elizabeth Smith and Patricia McDaniel for their input to this article. 

Fake news: is smoking really increasing in Australia?

6 Sep, 17 | by Becky Freeman, Web Editor

Author:  Simon Chapman AO

This blog post originally appeared on Doctor Portal and is published here with permission.

ON 14 August, 2017, The Australian newspaper ran a story guaranteed to go viral. The headline screamed: “More smokers lighting up, despite the costs”. The journalist, Adam Creighton, who has, grotesquely, written about tobacco control being like Nazism, reported on a claim being made by Dr Colin Mendelsohn, “an expert in public health at the University of NSW”, that:

“an unexpected standstill in the national smoking rate since 2013, combined with rapid population growth, has pushed up the number of regular smokers by more than 21 000”.

The article said that Australia’s smoking rate was now higher than the United States’ rate for the first time in a decade.

“This is despite plain packaging and the most expensive cigarette prices in the world.”

The claim was covered widely across Australian media, with Dr Mendelsohn interviewed several times. Senator David Leyonhjelm issued a press release repeating the claim, which would have pleased his party’s tobacco industry donors.

I received enquiries from the US and England asking me if the claims were true. I immediately called fake news. Here’s the real story.

The Australian Institute of Health and Welfare (AIHW) surveys national smoking prevalence every 3 years as part of its National Drug Strategy Household Survey. We also have annual data from England and the US on smoking rates with which we can compare Australia’s progress.

In 2013, there were 16.4% of Australians aged 18 years and over who smoked. By 2016, this number had fallen to 15.7%. By contrast, the US rate for 2016 is 15.8%, a sliver higher than Australia’s 2016 rate. England’s rate in 2016, according to the long running Opinions and Lifestyle Survey, was 15.8%, again marginally higher than Australia’s.

So, if anything, the smoking rate in Australia is identical to or marginally lower than in the US and England in 2016

Australia’s fall from 16.4% in 2013 to 15.7% in 2016 was not statistically significant. Dr Mendelsohn has stated publicly that Australia’s historically continual fall in smoking has therefore “flatlined”. This is an interesting claim because any student of statistics knows that while you can always draw a line between two points, you need a bare minimum of three data points to determine a trend line, including a flatline.

Dr Mendelsohn is an enthusiastic proponent of e-cigarettes and appears to be using international comparisons to justify a call for making these more available in Australia.

In the US, smoking actually increased from 15.1% in 2015 (the figure that Dr Mendelsohn was citing) to 15.8% in 2016, despite (or perhaps partly because of) the nation being awash with e-cigarettes. But like Australia’s statistically insignificant fall in smoking, the rise in smoking in the US was also not statistically significant (see figure 8.1 here).

If Australian smoking has flatlined, consistency would demand that he also say the same of the US, which doesn’t yet appear to have been done.

And what about the extra 21 000 smokers estimated? The figure of 21 000 can be found nowhere in the AIHW tables of figures. No nation reports its progress against smoking by quoting changes in the total number of smokers: the universal practice is to report rates (ie, percentages of the population).

There were about 2.4 million smokers in Australia in 1945 (when 72% of men and 26% of women smoked) – in a population of 7.5 million. This is about the same as the number of smokers in the population today. If we are to look only at the actual number of smokers, some might argue that we have therefore achieved nothing in 70 years, despite smoking prevalence today being 15.7% (or 12.8% if daily smoking is the measure).

Dr Mendelsohn appears to have arrived at a figure of 21 000 extra smokers by multiplying the percentage of daily smokers listed for each year in Table 3 of the AIHW report, with an estimate of population numbers of Australians 18 years and over in June 2013 and 2016 released by the Australian Bureau of Statistics in June 2017. These population estimates were published some months after the AIHW would have undertaken the analysis of smoking prevalence for 2016 and some years after it released its estimate of prevalence in 2013.

The estimate ignores the complexity of how survey results are weighted by population composition. It also ignores the fact that the prevalence figure is only an estimate, with margins of error. The AIHW’s table of relative standard errors and margins of error indicates that the prevalence of daily smoking among people aged 18 years and over in 2016 was somewhere between 12.2% and 13.4%. This means that the number of smokers in 2016 could have been anywhere between 2 293 000 and 2 512 000. A similar range applies to the figure for 2013. The calculation of an extra 21 000 smokers between 2013-2016 is therefore essentially meaningless.

Moreeover, the Australian Bureau of Statistics population figures show that between 2013 and 2016, Australia’s population aged 18 years and over grew by 864 340 people as a result of births, deaths and immigration. Many immigrants in this number would be from nations where smoking rates are high, particularly among men.

The elephant in the room? Massive growth in never smokers from smoking prevention.

Media attention has focused on smokers. But applying the same calculation Dr Mendelsohn has done for current smokers to people in the rest of the population, one would conclude that there are more than 870 000 extra non-smokers in Australia in 2016 than there were in 2013 — more than 80 times the number of extra current smokers (and more than 40 times the number of extra daily smokers) that he is so concerned about.

The impact of policies such as tobacco tax, plain packs and graphic health warnings is not just judged on smoker numbers, but on quitters and most importantly, in terms of prevention: the proportion of the population who have never smoked. The Australian National Drug Strategy Household Survey reported a significant decline in the percentage of young people smoking and a significant increase overall in the proportion of people who have never smoked — see the # symbols on Table 3 in the spreadsheet here. These figures indicate substantial achievements.

The article in The Australian declared “Australia’s punitive and coercive policies have run out of steam”. I assume this refers to successive Australian governments’ tobacco tax increases. The first of these increases in 2010 saw the CEO of British American Tobacco Australia, David Crow, telling a Senate committee in 2011:

“We understand that the price going up when the excise goes up reduces consumption. We saw that last year very effectively with the increase in excise. There was a 25 per cent increase in the excise and we saw the volumes go down by about 10.2 per cent; there was about a 10.2 per cent reduction in the industry last year in Australia.”

These are the same tax increases that a coalition of New Zealand experts announced vert recently that they want their country to adopt, emulating Australia.

The government’s recent mid-term report on its National Tobacco Strategy has also highlighted the need to improve cessation rates, but it has also provided an overwhelmingly positive picture of progress in Australia — see table 1 in the detailed report here.

We’d all like to see smoking prevalence fall even faster than it currently is. But to argue that we are going backwards or stalling is simply wrong.

Simon Chapman AO is Emeritus Professor of Public Health at the University of Sydney.

A missed opportunity: The US Helsinki Commission hearing on the illicit tobacco trade in the OSCE region

25 Aug, 17 | by Marita Hefler, News Editor

 

Benoît Gomis, Kelley Lee, Ross MacKenzie

benoitg@sfu.ca

 

On 19 July 2017, the US Commission on Security and Cooperation in Europe (CSCE) – also known as the ‘Helsinki Commission’ – held a hearing on the illicit tobacco trade in the Organization for Security Co-operation in Europe (OSCE) region. The Helsinki Commission, an independent US government agency created in 1976 to “press governments to improve their human rights records and allow, despite Europe’s division, expanded contacts between people”, has discussed a number of important challenges, including human trafficking, anti-Semitism, treatment of ethnic minorities, weapons proliferation, corruption and terrorism. Through hearings, briefings, and official delegation visits, the Commission gathers evidence on such issues and contributes to the formulation and implementation of US policy towards the OSCE and its participating states.

To date, limited progress has been achieved on the illicit tobacco trade in the OSCE region. Globally, illicit tobacco accounts for around 11.6% (600 billion sticks) of supply, and US$40.5 billion in lost tax revenues annually. Despite the size and profitability of the trade, the risk of detection is relatively low and penalties generally light. In Europe, the illicit tobacco trade is estimated to be between 6 and 10% of overall consumption. Its nature has evolved from predominantly large-scale smuggling to include illegal manufacturing, including counterfeit production, cheap cigarette brands produced specifically for illicit markets overseas, and overproduction of regular cigarette brands. Overall, the illicit tobacco trade in the OSCE region reportedly stems from a murky blend of tobacco companies, including transnational tobacco companies (TTCs), and criminal elements, which both cooperate and compete for this lucrative trade. The latter includes criminal organizations which earn substantial income, while fuelling money laundering, corruption and other illicit activities. From a public health perspective, the illicit tobacco trade makes cigarettes more affordable and accessible, especially among youth and low-income populations, resulting in higher consumption.

In this context, a high-level public hearing by a US government agency on the issue of illicit tobacco trade is a much welcomed and timely opportunity to enhance understanding of the nature of the illicit trade in the OSCE region, the factors driving it, and the wider implications for the global community. This hearing is especially important given that the WHO Framework Convention on Tobacco Control (FCTC) Protocol to Eliminate Illicit Trade in Tobacco Products, adopted on 12 November 2012, has still to come into effect. At the time of writing, only 29 countries are party to the Protocol, with 12 more needed by 2 July 2018 for it to come into force. The US has yet to ratify the FCTC itself or sign the Protocol.

Unfortunately, given the selected range of issues addressed, and how they were framed in discussions, it is doubtful whether the hearing yielded any new insights. The panel of witnesses was composed of Louise Shelley, Professor of Public Policy at George Mason University, who researches transnational crime, terrorism and corruption, including the crime-terror nexus; David Sweanor, Adjunct Professor at the Faculty of Law, University of Ottawa, and a leading tobacco control expert whose areas of advocacy and research include extensive experience in analysing, monitoring, and litigating on, the global illicit cigarette trade; and Mark Firestone, Senior Vice President and General Counsel at Philip Morris International (PMI). While Sweanor and Shelley brought long standing experience in the illicit tobacco trade to the hearing, it notably did not include any representatives from law enforcement, regional experts, officials from any relevant international organization (e.g. WHO, Interpol, Europol, World Customs Organization, World Bank, United Nations Office on Drugs and Crime, or OSCE), or academics who have published relevant research on illicit tobacco.(see examples here, here, here and here.

The involvement of a representative of a leading transnational tobacco company in the panel seems particularly incongruous given substantial evidence of historical tobacco industry complicity in cigarette smuggling (see examples here and here)  and reports of their continued involvement. Tobacco companies have also generated inaccurate estimates of the size and nature of the illicit trade, and overstated the role of taxation, advertising restrictions, and packaging and labelling regulations as contributing factors. Further, industry lobbying against the illicit trade has focused on counterfeit products, a small portion of the total illegal cigarette market, as a distraction or means to further its own interests.

Guarding against industry interference is a key provision under the FCTC. Article 5.3 concerns the need for Parties to protect public health policies from “commercial and other vested interests of the tobacco industry”. Article 5.3 implementation guidelines recognise that some “interactions with the tobacco industry are necessary”, but recommends that these interactions be conducted in public, “for example through public hearings”. While the Helsinki Commission hearing was publicly held, as stated above, the odd balance of expertise, particularly the inclusion of a tobacco company representative, raises questions about industry interference.

Testimony provided raised a number of important points. Overall, however, the hearing did not adequately address four important issues. First, the complicity of the tobacco industry in the illicit tobacco trade was barely mentioned, as well as the ineffective law enforcement partnerships several tobacco companies have established with governments around the world. Instead, much of the discussion on the private sector focused on the role of new media in allowing users to post details about opportunities to purchase illicit cigarettes. Similarly, the growing role of tobacco companies independent of transnational tobacco companies, most notably in Asia, positioning themselves to ‘go global’ through legal and illicit trade, was not discussed. Effective efforts to address this substantial source of illegal activity depends on better understanding this complex and changing picture.

Second, there were several instances in which tax increases were brought up as the primary driver behind the illicit tobacco trade. This is a familiar industry-led narrative despite overwhelming evidence that this is not the case.

Third, there is an urgent need for independent data collection and analysis on the illicit trade. In many regions, the tobacco industry itself is the source of this information, even supplying data to public officials. Without reliable information on the scale of the problem and trends over time, it will be impossible to know how effective efforts are to curtail this illicit trade.

Finally, the importance of strengthening institutional capacity against the illicit trade was not discussed in depth. This would involve public health, customs and excise, and law enforcement agencies – with additional resources for a lead coordinating body, public awareness campaigns, and targeted enforcement along the entire production and distribution network including addressing the industry’s complicity.

Benoît Gomis is a research associate at Simon Fraser University, Canada where he focuses on the illicit tobacco trade in Latin America and the Caribbean, and an international security analyst. Kelley Lee is a Tier 1 Canada Research Chair in Global Health Governance, Simon Fraser University. Ross MacKenzie is a lecturer in Health Studies at Macquarie University, Australia. Their work is supported by the National Cancer Institute, US National Institutes of Health, Grant R01-CA091021

*This article was amended on 31 August 2017 to include additional details about the qualifications and experience of Louise Shelley and David Sweanor.

India: steep decline in tobacco consumption in India reported in second Global Adult Tobacco Survey (GATS 2017)

23 Jun, 17 | by Becky Freeman, Web Editor

Authors: Chaturvedi Pankaj , Sarin Ashima, Seth Sanjay, Gupta PC

On 8th June 2017, results from the second Global Adult Tobacco Survey (GATS 2) of India were released. GATS is a global standard for systematically monitoring adult tobacco use and tracking key tobacco control indicators. India is the world’s largest democracy, and the second largest consumer and third largest producer, of tobacco. Tobacco control results from India take on a global significance in terms of impact on total mortality and disease burden.

For a large and diverse country like India, effective tobacco control has always been a daunting task. In the last five years, the country has witnessed a number of legal battles between the government and the tobacco industry. At one point, a parliamentary committee supported the tobacco industry and sought dilution of certain tobacco control measures. The powerful tobacco lobby tries to delay or derail attempts to reduce tobacco use prevalence. According to media reports, the Health secretary and Health ministers were removed from their posts in part because of their support of tobacco control measures. GATS 2 is can be viewed as a report card of the Government’s action on tobacco control.

GATS 2 was a household survey of 74,037 persons, aged 15 or more, conducted in all 30 states of India and two union territories in 2016-17. The first GATS was conducted in 2009-10. GATS 2 results found a 6% decline in tobacco use prevalence, from 34.6% in GATS 1 to 28.6% in GATS 2. The decline in prevalence was equivalent to a 17% relative decrease, and the number of tobacco users has reduced by about 8.1 million. The GATS 1 data released in October 2010 reported an estimated absolute number of 275 million tobacco users in India. The 2017 National Health Policy of the Government of India had set a target of relative reduction in current tobacco use by 15% by 2020; a target which has now been exceeded. The next target is a 30% reduction by 2025.

This period also witnessed the emergence of new contributors outside the Ministry of Health providing additional powerful tools for tobacco control. The Ministry of Women and Child Development amended the Juvenile Justice Act to make the sale of tobacco to minors as a non bailable offence punishable by 7 years of rigorous imprisonment and a fine of up to 100,000 Indian Rupees (US1550). The Department of Consumer Affairs amended the Legal Metrology Act to prohibit sale of loose cigarettes, which currently accounts for over 70% of the country’s total cigarette sales.

Meanwhile, a regulation under the Food Safety Act (2011) prohibited addition of tobacco and nicotine to any food substance. Through public interest litigation, this regulation enabled the Supreme Court to order a nationwide ban on gutka (a combination of flavored smokeless tobacco and areca nut). In addition, more than a dozen states have independently prohibited flavored smokeless tobacco products – an important step given gutka is a risk factor for oral cancers.

Voice of Tobacco Victims (VoTV), a campaign led by doctors and tobacco victims, played a pivotal role in the getting gutka/smokeless tobacco banned and taxes hiked on various tobacco products in India. The campaign has won awards and recognition from several organizations such as the World Health Organization, British Medical Journal, and the Campaign for Tobacco Free Kid. While most believed that prohibition would not work, VoTV was convinced that it would lead to decreased accessibility and affordability translating into reduced youth initiation. The 360-degree campaign involved advocacy, a legal battle, media, and research. The VoTV network also reached several medical societies and hundreds of individual doctors to increase engagement in tobacco control advocacy.

Despite tremendous resistance and litigation from the tobacco industry, the Ministry of Health imposed an 85% pictorial warning on tobacco packets from 1st April 2016. A significantly higher proportion of adults considered quitting because of the warnings on tobacco products (61.9% current cigarette smokers thinking about quitting smoking GATS 2 versus 38% in GATS 1). The tobacco tax hikes also contributed to reduction in prevalence, with individual expenditure on cigarettes and bidis having tripled since GATS 1.

GATS 2 reported a reduction in smokeless tobacco users from 25.9% to 21.4%. It also affirmed that a smokeless tobacco ban would not lead to switching to smoking. Smoking prevalence between the two GATS survey declined from 14% to 10.7 %, despite the ban on gutka/smokeless tobacco.

Summary of GATS 2 tobacco use

Pattern of tobacco

  • 6% of adults aged 15 and above (267 millions) used tobacco in any form
  • 199 million use smokeless tobacco, 100 million smoke tobacco and 32 million smoke as well as chew tobacco.
  • The most commonly used tobacco products are khaini (a type of smokeless tobacco) 85 million users and bidi (hand rolled cigarette) 67 million users.
  • 199 million users live in rural area and 68 million in urban

Significant changes compared to GATS 1

  • 17% relative decrease in tobacco prevalence
  • Tobacco use among 15-24 year olds showed relative reduction of 33% and for 15-17 year olds there was a 54% reduction.
  • The age of initiation of tobacco use increased by 1 year ( 17.9 to 18.9).
  • While there was a decrease in second-hand smoke exposure in public places (6%) and at home (13%), there was no decrease in workplaces.
  • 9% (83 % to 92%) more believed that second-hand smoke is harmful
  • 7% (89% to 96%) more believed that smokeless tobacco is harmful

Areas of concern

  • 68% of smokers, 17% of bidi smokers, and 50% of smokeless tobacco users purchase loose tobacco.
  • 30% of those who work indoors are exposed to second-hand smoke
  • 23% adults are still exposed to SHS at public places.
  • Nearly 10% of people still notice some form of tobacco advertisement.
  • Despite the gutka ban, 51 million people were still able to buy gutka

We must commend Government of India for their commitment to Tobacco Control. We also recognize the efforts of several national/international NGOs, academic institutions and civil society activists who have contributed to this impressive result. GATS 2 demonstrates that the tobacco control strategies in India are going in the right direction. For continuing improvement, the country needs further strengthening of policies, particularly enforcement of tobacco control laws.

World No Tobacco Day 2017: how different countries are celebrating

31 May, 17 | by Marita Hefler, News Editor

This page brings together coverage from around the world of World No Tobacco Day. It will be updated regularly with tweets, photos and links to news coverage.

The theme of World No Tobacco Day 2017 is Tobacco – a threat to development. 

New Zealand started with a world first by announcing that its military will become completely smoke free by 2020. Read the story here. There is still much to be done in New Zealand to achieve the government’s goal of being smoke-free by 2025.I

In Australia, there is strong action being taken by Aboriginal and Torres Strait Islander health services to reduce the high smoking prevalence among Indigenous people.

In Indonesia, the National Commission on Tobacco Control is urging the government to sign the WHO Framework Convention on Tobacco Control. Read the story here.

Nigeria is a country in the sights of the tobacco industry. Smoke Free Nigeria is saying #NoTobacco.

In Austria, a new study released to mark WNTD has found that increasing the price of tobacco by 5%, it will result in a drop in consumption of 3.5%. Read the study here. 

In the USA, ASH has released a new report highlighting how the country is falling behind other countries – and it is the most vulnerable who are paying the price.

https://twitter.com/AshOrg/status/869559802283917314

New Zealand to have world’s first smoke-free military by 2020

31 May, 17 | by Marita Hefler, News Editor

New Zealand has kicked off World No Tobacco Day by announcing a plan for its defence force to become the world’s first smoke-free military by 2020.

Initiatives to achieve the goal include banning the sale of cigarettes on camps and bases and making NZ defence force housing smokefree. It will also evolve camps and bases into smokefree environments, and continue to promote and support smoking cessation and the benefits of a smokefree NZ defence force.

The plan was announced at an event hosted by ASH New Zealand in Parliament to mark World No Tobacco Day. ASH Chair, Emeritus Professor Robert Beaglehole welcomed the plan. “This is a huge milestone, the New Zealand Defence Force is one of the largest employers in New Zealand with over 14,000 personnel, and the biggest Government department to go smokefree.”

The 2020 target date is five years ahead of the New Zealand government’s Smoke Free 2025 goal, which aims to reduce adult daily smoking prevalence to below 5%.

“ASH applauds the NZDF, not just for their commitment to the 2025 goal, but for showing the leadership to beat the goal by five years. We hope this decisive action can be an example to other government agencies and major employers of the type of leadership needed to reach Smokefree 2025” Beaglehole added.

While the 2020 goal is a welcome step forward, Beaglehole noted “Progress towards the Government’s smoke free 2025 goal is far too slow, especially for Maori and Pacifica, and poor people generally. There are also simple measures the government can introduce, such as increasing targeted mass and social media campaigns. ASH is committing our resources to supporting all policymakers to set a strong, evidence based roadmap to get us to Smokefree 2025”.

Fashion and smoking: Celebrities “rebel” at the MET Gala

4 May, 17 | by Becky Freeman, Web Editor

Fashion and the tobacco industry have a long and intertwined history. Dated images of fashion models smoking while looking impossibly glamorous seem clichéd and old fashioned. Now, smoking is more a symbol of addiction, death, and corporate manipulation – no longer is smoking shorthand for rebellion, coolness and aspiration.

But, that didn’t stop celebrities attending the biggest and most celebrated fashion event of the year, the MET gala, from trying to resurrect smoking’s tarnished image. The event, held in New York as a fundraiser for the Metropolitan Museum of Art’s Costume Institute, receives global media coverage with lead stories in the news, gossip, fashion, and lifestyle pages. It also spawns thousands of social media posts highlighting both the celebrities in attendance and their avant-garde fashion choices.

For example, the American fashion designer, Marc Jacobs, posted an image of himself smoking during the event in the “girls room” with celebrities Courtney Love (herself a paid spokesperson for NJOY e-cigarettes) and her daughter Frances Bean. The Marlboro cigarette packet can be clearly seen in Mr Jacobs’ hand. Associating the Marlboro brand with exclusivity, celebrity, fashion, and rebellion – smoking is illegal inside public buildings in New York.

No doubt Philip Morris is pleased to see its brand being held up as a fashion accessory. It sure beats being known for killing 2 out 3 of your best customers.

Smoking in the girls room #metgala @chardefrancesco @courtneylove @space_witch666

A post shared by Marc Jacobs (@themarcjacobs) on

Smoking in the girls room #metgala @chardefrancesco @courtneylove @space_witch666

A post shared by Marc Jacobs (@themarcjacobs) on May 1, 2017 at 6:31pm PDT

A Tobacco Endgame for Scotland?

25 Apr, 17 | by Marita Hefler, News Editor

A Tobacco Endgame for Scotland?

Katherine Smith and Jasper Been

An editorial in the November 2016 edition of Tobacco Control argued that talk about ‘tobacco endgames’ and policies that go ‘beyond ‘business as usual’ is becoming mainstream in a small number of countries, of which Scotland is one (others include New Zealand, Canada, Finland and Ireland). The race is now on to see which of these countries will be first to cross the finishing line. Attendees at a recent meeting on developing Scotland’s tobacco ‘endgame’ strategy identified three key policy priorities for a Scottish ‘tobacco endgame’: restricting availability of tobacco; pursuing a ‘polluter pays’ approach with tobacco industry profits; and introducing incentives for disadvantaged smokers to quit.

Tobacco Control in Scotland

Scotland is one of many countries that have taken major steps to reduce tobacco use, and related health harms, in recent decades. Having been a leader in the establishment of smokefree public places, Scotland’s current tobacco control strategy, launched in 2013, was bold in its commitment to Scotland becoming ‘smokefree’ (defined as adult smoking rates of 5% or less) by 2034. If this ambitious aim is to be achieved, it will require radical policy initiatives, consistent with recent proposals for tobacco ‘endgame’ scenarios. To date, however, there has been limited discussion of what specific policies ought to be pursued in Scotland to achieve the 2034 ‘smokefree’ goal.

In order to start addressing this gap, on 24th October 2016, an Usher Institute of Population Health Sciences and Informatics/ESRC supported seminar took place in Edinburgh in which researchers, advocates, policymakers and practitioners came together to discuss what a tobacco ‘endgame’ for Scotland might look like. The session involved multiple presentations and ‘pitches’ for policy proposals from a range of experts. Everyone present then had the opportunity to put forward potential policy proposals before collectively voting to identify those with greatest support.

What is a ‘tobacco endgame’?

The concept of ‘tobacco endgames’ is an analogy taken from the game of chess, the idea being that when you’ve got fewer pieces on the board (towards the end of the game), you need to change tactics to win. In public health terms, talking about tobacco endgames marks an important shift in focus towards ‘seeking to end the tobacco epidemic, rather than control it’. Since ‘the essence of the endgame requires thinking outside the box’ the kinds of proposals that are put forward as potential tobacco endgame strategies are often rather more radical than those that we have seen implemented to date.

A recent review of tobacco endgame proposals identified a four broad potential strategies. Some focused on the product itself, others on restrictions for users, while others focused on the market and structural issues:

  • Product– make cigarettes less addictive or appealing, or implement strategies to displace combustible cigarettes with the less harmful alternative of e-cigarettes.
  • Users – restrict access through smokers’ licences or prescriptions for purchasing tobacco, as well as incrementally increase the legal age of purchase to gradually phase out tobacco.
  • Market mechanisms – reduce retail availability, ban combustible tobacco products, make non-combustible nicotine products easier to purchase than combustibles, restrict manufacture and importation of products, price caps.
  • Structural – create a new tobacco control agency, create a regulated market, state takeover of tobacco companies, introduce a performance-based regulation system.

Does Scotland need a ‘tobacco endgame’?

Devolution afforded Scotland a ‘window of opportunity’ in addressing public health challenges. The Scottish Government has implemented a range of tobacco control policies including banning smoking in enclosed public spaces, outlawing vending machines and point-of-sale displays, and, most recently, banning smoking in cars carrying children. While most of these policies have now been implemented in other parts of the UK, Scotland has demonstrated clear public health leadership in this area and its commitment to becoming ‘smokefree’ (i.e. adult smoking prevalence of 5% or less) by 2034 indicates a desire to continue leading on tobacco control.

Reflecting these developments, smoking rates are coming down and we now have the lowest rates of smoking among young people and adults that Scotland has seen in decades. There has also been a significant decrease in the proportion of children exposed to second-hand smoke (from 11% in 2014 to 6% in 2015), following a successful government campaign on this topic. However, the latest data suggest around 21% of Scotland’s population smoke, a figure that is still higher than other parts of the UK. Also, while smoking prevalence is decreasing across all social groups in Scotland, a marked social gradient in smoking rates still exists. Moreover, to achieve the endgame targets we will need a much more rapid decline in smoking amongst the most disadvantaged compared to more affluent groups.

All of this poses some significant challenges. Most pressing is how to reduce smoking in Scotland’s poorest and most disadvantaged communities (including, for example, those experiencing mental ill-health) while avoiding the stigmatisation of those who find it most difficult to quit smoking (and evidence here is limited). Increasing the price of tobacco is the only specific intervention consistently shown to have a positive equity effect in terms of smoking prevalence. Yet, while traditional tobacco taxes are progressive in health terms by promoting cessation, they are regressive in economic terms for those who don’t quit, and such taxes can exacerbate the stresses and material impacts of life on a low income. These broader effects have only recently begun to be studied and have not yet been explored in a Scottish context.

What kinds of approaches were suggested for Scotland?

Having had an overview of the ‘endgame’ options outlined above, four broad policy pitches for Scottish approaches were put forward at the event, before participants went on to suggest four broad and interlinked policy proposals:

  1. Re-orientating tobacco control to take a broader social determinants approach, focusing on addressing the underlying drivers of tobacco use, especially in poorer communities. This involves thinking about some of the upstream drivers of tobacco use, including the efforts of the tobacco industry. Evidence indicates that tobacco control in Scotland, as in many other contexts, is now overwhelmingly an inequalities issue and should therefore be addressed as such.
  2. Framing tobacco control as a human rights issue (especially for children) on the basis of the right to health and associated rights. Scotland is (usually via the UK) party to a range of international and regional human rights treaties, including the International Covenant on Economic, Social, and Cultural Rights and the Convention on the Rights of the Child, which means that the Scottish government can use obligations set out in these legal documents to help make the case for further tobacco control measures, especially where these protect children from tobacco use and exposure.
  3. Measures to reduce the local provision of tobacco retailing, which is currently ubiquitous across Scotland. Strong research evidence demonstrates the links between neighbourhood density of availability and smoking prevalence. Availability is also part of the inequalities story since the density of tobacco outlets in Scotland varies geographically, with deprived neighbourhoods having about 77% more places to buy tobacco than more affluent areas. So environments are currently heavily loaded against poorer communities and this needs to be addressed. Scenario modelling in New Zealand looked at the impacts of reducing density around schools, removing licenses and an overall availability reduction of 95%. This work suggests positive impacts in terms of raising prices of tobacco products and reducing smoking prevalence. We need to do similar work in Scotland.
  4. Strengthening and extending regulation of tobacco as an industrial epidemic. While measures have been taken to prevent the tobacco industry influencing health policy, its expanding interest in new technologies such as e-cigarettes potentially re-opens the policy door to tobacco industry interests. For some, this might be seen as offering tobacco industry interests a ‘way out’ through harm reduction, a route Philip Morris International has presented itself as considering. In contrast, this pitch suggested a need to continue to focus on the role of the tobacco industry, and for regulation to be increasingly shaped by the ‘polluter pays’ principle. This could form part of a wider approach to regulating producers of unhealthy commodities, including alcohol, as modifiable structural determinants of health.

Running across several of the pitches, there was also a plea to work collaboratively with those communities most negatively affected by tobacco use and associated health inequalities. This could help inform policy debates about what approaches are publicly supported and reduce the risk of stigmatising poorer communities.

What specific policies were suggested and which were most popular?

After hearing the pitches, the 37 participants formed small groups to consider specific proposals for a tobacco endgame in Scotland. Each group’s proposals were collated and similar suggestions combined. This resulted in 14 distinct policy proposals that were voted on anonymously by the participants (each participant had three votes). The bar chart below demonstrates that the three most popular strategies involve: restricting availability of tobacco around schools, pursuing a ‘polluter pays’ approach with tobacco industry profits (and investing revenue raised for health) and introducing incentives for disadvantaged smokers to quit (a policy that has already been successfully trialled for pregnant women in the West of Scotland but which is currently not in place).

 

 

 

 

 

What next?

Overall, participants at the seminar seemed broadly supportive of the idea that Scotland now needs to develop a clearer conception of a tobacco endgame. Admittedly this only reflects the views of an invited group of health professionals (researchers, practitioners, policymakers and advocates) whose concerns focus on improving public health and reducing health inequalities. For others, the idea of a tobacco endgame might seem at odds with a liberal policy environment, or else simply feel impractical. Nonetheless, if the Scottish Government is serious about achieving a smokefree Scotland by 2034 then we need to advance discussion about potential ways forward. This becomes pressing given that Scotland’s current tobacco control strategy ends in 2018, with endgame thinking having an opportunity to shape development of a new strategy. The suggestions emerging from this event represent a further contribution, as do those from bigger events such as the 2016 Scottish Smoking Cessation Conference, but discussions also need to become far broader, public, and inclusive. Given the risks of stigmatising smokers, particularly those living in more deprived communities, it will be particularly important to engage these groups in such discussions and this is a topic that researchers in GRIT (the Group for Research on Inequalities and Tobacco) will be pursuing.

Katherine Smith is a Reader in the Global Public Health Unit and member of GRIT (Group for Research on Inequities and Tobacco at the University of Edinburgh. Jasper Been is a member of the Usher Institute of Population Health Sciences and Informatics at the University of Edinburgh and Erasmus MC-Sophia Children’s Hospital, Rotterdam, Netherlands.

Acknowledgements:

Thanks are due to everyone who participated in the 24th October 2016 seminar and to Ash Scotland and GRIT (the Group for Research on Inequalities and Tobacco), the Chief Scientist Office of the Scottish Government, the Farr Institute and the Usher Institute at the University of Edinburgh, for supporting this event. We also acknowledge ESRC funding for this event via a seminar series grant (‘Tobacco and Alcohol: Policy challenges for public and global health’, Grant No. ES/L001284/1). Finally, we would like to thank Lynn Morrice and Rebecca Campbell for organising practical aspects of the event.

 

France: breaking new ground in tobacco control

2 Mar, 17 | by Marita Hefler, News Editor

The start of 2017 has seen tobacco control in France boosted with a series of ground-breaking tobacco control measures, as detailed in a recent article by Physicians for a Smoke-Free Canada.

After a phase-in period, cigarette plain packaging is fully in force as of 1 January 2017. As in other countries that have already introduced plain packaging, or are planning to do so, the tobacco industry and its mouthpieces fought strongly against the new law.

In a move which extends the impact of plain packaging, the French government has also applied Directive 2014/40 of the European Union, which directs member states to restrict tobacco presentation. On February 1, 2017 a regulation was issued that identifies product names judged to be contrary to the European Union Directive. The identified names will only be authorised for sale for one more year in France. Among the brand names and descriptors that will disappear from 2018 under the regulation are Vogue, Virginia Slims, Anis (licorice), Menthol and Biodegradable.

France has also introduced a new tax on tobacco company revenue. Expected to raise about 130 million Euros per year, the new funds will be used to finance further tobacco control initiatives. The measure is particularly significant because it closes a  loophole used by tobacco companies to avoid France’s high-tax regime.

To read the full details on the Physicians for a Smoke-Free Canada website click here.

Is Philip Morris’ claim it wants to phase out conventional cigarettes credible?

1 Dec, 16 | by Marita Hefler, News Editor

In recent months, Philip Morris International has been claiming it wants to lead the push to a smoke free world and  wants to work with governments towards the phase out of conventional cigarettes. The claims have been met with scepticism, but do they stand up to scrutiny?

At an investor day held in late September 2016, PMI chief executive officer Andre Calantzopolous outlined the company’s strategic priorities, which include “to continue leading the combustible product category and deliver against our current growth algorithm” and for “Reduced risk products (RRPs) to ultimately replace cigarettes to the benefit of all stakeholders”. Calantzopoulos described the ‘excellent combustible fundamentals’ which include: improving cigarette industry volume/trend mix, and broad and balanced geographic footprint with expansion opportunities. While these are not exactly the words of a leader who wants to get out of the cigarette business, he also states that the company is committed to achieving widespread conversion to RRPs, and that PMI “welcome all alternatives to achieve a combustion-free world as quickly as possible.” Together these contradictory priorities sound very much like a bet each way.

At first glance, the latter rhetoric sounds like the company has finally – after more than 50 years of denial and deceit about the harms of tobacco – realised that not only is the tobacco business ethically and morally bankrupt, but it is also the wrong profit-making horse to back. However, a closer look suggests that reduced risk products may be yet another cynical tactic for the company to position itself as a socially responsible entity that deserves to be treated as part of the solution, rather than the problem.

The glaring omission in the rhetoric is the most obvious alternative for PMI to meaningfully contribute to achieving a combustion-free world: announce a date by which the company will phase out combustible products entirely. Calantzopoulos is on record as stating the iQOS (I Quit Ordinary Smoking) technology which appears to be the platform it is pinning most hope on, put the industry “on the cusp of a revolution”. At the September meeting, he told investors that almost one million smokers have already converted to RRPs and it had captured nearly 3% of the Japanese cigarette market. Wells Fargo Securities tobacco analyst Bonnie Herzog estimates that iQOS could displace 30% of the global combustible market by 2025.

At the September 2016 investor day, Calantzopoulos was not shy about framing RRPs as a public health solution with enormous potential, claiming “…if we can encourage a meaningful portion of adult smokers to rapidly switch to RRPs that meet this standard, it is likely to create a significant additional population health benefit relative to current regulatory efforts.” He called on the public health community to embrace this approach, and noted “we are very much encouraged by the growing number of pre-eminent public health advocates that already support the principle of tobacco harm reduction through products and science.”

The public health community has seen similar promises before: the promise of reduced risk products is nothing new, and the safety of iQOS is largely untested. If these products fail, as their predecessors have done, PMI will have benefited from iQOS and other reduced risk products being branded consistently with its combustible tobacco products.

Presumably anticipating such objections, Calantzopoulos noted, “I fully recognise there is scepticism and a deficit of trust in our determination to lead the effort to achieve a combustion-free world as soon as possible. Although we cannot change the past, we can certainly change the future and transform our company.”

Indeed, PMI can certainly change the future and transform the company. Nothing will accelerate the transition to a smoke free world more effectively than PMI withdrawing completely from the combustibles market, supported by the intensive consumer engagement strategies it is already using to promote uptake of iQOS.

Public health advocates who are willing to work with the tobacco industry on joint harm reduction approaches would do well to remember the fable of the scorpion and the frog, in which the frog agrees to carry the scorpion across a stream. Halfway across, the scorpion stings the frog. As they both start to drown, the frog asks ‘why?’, to which the scorpion replies ‘it’s my nature’.

This is an edited version of an article which was published in the Worldwide News & Comment section of the November edition of Tobacco Control. 

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