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Archive for February, 2015

The European Tobacco Products Directive and the Tobacco Industry

26 Feb, 15 | by Becky Freeman, Web Editor

Listen to this BMJ talk medicine TC podcast discussion with Silvy Peeters, University of Bath, about her paper:

The Revision of the 2014 European Tobacco Products Directive: An Analysis of the Tobacco Industry’s Attempts to ‘break the health silo’

The full paper is also freely available to all as an open access publication.

Should stores selling tobacco be allowed to provide publicly funded health services?

11 Feb, 15 | by Marita Hefler, News Editor


Dr Andrew Furber

Follow Dr Furber on Twitter at @FurberA

Imagine a patient with a health problem accessing a publicly-funded health service where the substance causing the problem was on sale within the same premises. You would probably think this was completely unethical. But this is exactly what happens in hundreds of supermarkets in the United Kingdom every day.

The provision of accessible health services, including where people shop, is a good thing. However as National Health Service (NHS) England has recently made clear in their Five Year Forward View, health services must be as focused on the prevention of illness as they are on its cure.

Tobacco remains the leading cause of preventable mortality and morbidity and causes 80,000 deaths in England every year. Although smoking prevalence is declining in the United Kingdom, recently falling below 20% for adults in England, tobacco will kill half of its regular users. Around one in ten of the current UK population will die from smoking. Smoking is strongly correlated with socioeconomic deprivation and is the main behavioural determinant of health inequalities.

So why is such a toxic substance to be sold from supermarkets which provide NHS services when it has such a devastating effect on the health of individuals, families and the nation?

Recently the CVS chain of pharmacies in the United States decided to stop selling tobacco . The company felt these sales were incompatible with its aim of being recognised for its role in healthcare.

So why do UK supermarkets continue to sell tobacco? The answer is probably to act as a lead product which brings customers in, who then purchase other items. Tobacco sales are likely to have a small margin for the retailer. Most of the cost of a packet of cigarettes goes on tax or to the tobacco company. The risk for any supermarket that unilaterally decided to stop selling tobacco would be the possibility of losing nearly one in five of its customers to its competitors. However if none of the major supermarkets sold tobacco it is unlikely that any of them will lose custom. People will still shop at supermarkets as they do now.

Supermarkets might argue that this is a slippery slope. If tobacco sales are not permitted what would be next? Alcohol? Foods with high fat, sugar or salt content? Well, no. Tobacco is uniquely dangerous. There is no safe level of tobacco consumption, whereas alcohol, fat, sugar and salt can all be consumed in moderation without any harm to health.

Is there a plan B if supermarkets indicate they would rather sell tobacco than provide NHS services? Possibly: a compromise could be to require supermarkets providing NHS services to provide information and advice at the point of tobacco sale on smoking cessation services. They could also supply tobacco sales data (which should apply to all tobacco retailers through a system of licensing) to assist authoroities with local tobacco control efforts.

Another alternative is a supplementary charge on business rates paid by large stores selling tobacco. This has been tried in Scotland in the Government Health Levy, and applies to outlets with a rateable value of more than £300,000 selling alcohol or tobacco.

If health services are to get serious about the prevention of ill health then they can have no association with its main behavioural cause – tobacco. It’s time for NHS contracts to reflect this.

Dr Furber is the Director of Public Health for Wakefield Council, UK. The opinions expressed in this article are the author’s personal views and do not necessarily represent the views of his employer or other associated institutions.

India: Government consultation to strengthen National Tobacco Control Law

9 Feb, 15 | by Marita Hefler, News Editor


Amit Yadav & Monika Arora, Public Health Foundation of India

Two months after announcing larger and stronger pictorial health warnings on all tobacco products, and 10 years after ratifying the WHO Framework Convention on Tobacco Control (FCTC), the Ministry of Health and Family Welfare, the Government of India is proposing to amend and strengthen the national tobacco control law (COTPA 2003), to better align with both the FCTC and international best practice. As part of pre-legislative consultation, the government is seeking input from key stakeholders and the general public. Comments and views about the Amendment Bill will be accepted until 15 February 2015.

The proposed amendments include:

  • Protection of tobacco control policies from the tobacco industry: One objective of the proposed law is “to protect the development and implementation of public health policies with respect to tobacco control from the commercial and other vested interests of the tobacco industry,” to comply with Article 5.3 of the FCTC.
  • Amendments to the definitions to avoid ambiguity: Key terms like advertisements, indirect advertisements, medium, promotion, public place, sponsorship, trademark and tobacco industry have been clearly defined under the published draft amendments.
  • Protection from exposure to tobacco use: The draft amendment proposes to prohibit smoking in all public places but allows designated smoking areas at international airports. Since smokeless is a prominent form of tobacco use in India, this section of the Bill includes prohibition on use of any kind of tobacco products in public places.
  • Prohibition on tobacco advertisement, promotion and sponsorships (TAPS): Draft amendments comprehensively prohibit TAPS, including surrogate advertisements and brand extensions. COTPA 2003 allowed advertising at point of sale and on packs. The draft Bill proposes to remove these concessions. It also prohibits sale of any article resembling tobacco products and distribution of free samples of tobacco products. It also prohibits sponsorship, through any mark or trademark or brand name of cigarettes or other tobacco products.
  • Prohibition on corporate social responsibility by tobacco companies: The Amendment Bill prohibits any promotion of tobacco products through contribution or otherwise, or through an activity under corporate social responsibility, by or of a company engaged in the manufacture or production of cigarettes or any other tobacco products.
  • Protection of minors from exposure to tobacco: The proposal increases the age of access from 18 to 21 years, while also proposing to prohibit sale of tobacco products in loose and single sticks.
  • Packaging, labeling and product regulation: The proposed Bill mandates pictorial warnings on the principal display areas similar to provision of COTPA 2003, but also mandates disclosure of content information (and emissions of each cigarette) on tobacco product packages.
  • Increased penalties on violation of the law: Pecuniary penalties for compoundable offences will be increased from the present INR 200 (USD 3.3) to INR 1,000 (USD16.5). Other offenses in the Bill are proposed to be “cognizable” and pecuniary penalties therein are increased by about 10 times from the current ones.
  • Licence cancellation for violation: To ensure compliance with the provisions, the amendment Bill authorizes competent authority to suspend or cancel license of the manufacturer or producer, importer, supplier, distributer or seller, for a period as the competent authority may deem fit.

The proposed amendments will go a long way towards advancing tobacco control in India. However the draft Bill still requires further strengthening to be in line with global best practices. This pre-legislative consultation period provides an excellent opportunity to tobacco control experts in India to review challenges faced in enforcement of COTPA 2003 and feed those experiences into drafting the current Amendment Bill. It is important to make the Bill comprehensive and robust to avoid its exploitation by the tobacco industry.

A PDF of the proposed Amendment Bill is here: COTPA Amendment Bill-2015 or access it through the Ministry of Health & Welfare website here:

Feeback can be provided by 15 February 2015 to: 

Shri R. S. Negi

Under Secretary (Tobacco Control)

Department of Health and Family Welfare

Room No-425 ‘C’, Nirman Bhawan

New Delhi-110011

Email: or

Indonesia: tobacco pack warnings need stronger enforcement

8 Feb, 15 | by Marita Hefler, News Editor


Widyastuti Soerojo, Southeast Asia Initiative on Tobacco Tax

As reported in the September 2014 edition of News Analysis, pictorial health warnings (PHW) on cigarette packs in Indonesia were due to be implemented in June 2014. The Indonesian government approved the warnings, after a lengthy process, under Article 114 of the Health Law No 36/2009, with 18 months lead-in time from approval to implementation.

Considering Indonesian tobacco companies have been exporting cigarette packs with pictorial warnings to neighbouring countries for many years, 18 months was extremely generous to the tobacco industry before mandating Indonesians receive the same information as other people in the region about smoking’s dangers. Nonetheless, by 24 June, only about 13% of brands were reported to be compliant with the new law. The tobacco industry was then given a further two months to comply, bringing the transition period to a total of 20 months.

The Faculty of Public Health, University of Indonesia coordinated a survey in the last week of August 2014 – the end of the extended implementation period – to assess the progress of compliance at points of sales (POS). The survey was done in 54 subdistricts of seven cities of seven provinces in Java, including the capital Jakarta and less densely populated outer islands. The National Commission for Child Protection together with researchers from universities in Banda Aceh, Pontianak, Makassar, Jakarta, Semarang and Surabaya surveyed 525 POS. Each covered 10 randomly selected POS in five categories: distributor to retailer, supermarket, minimarket, kiosk and vendor.

No cigarette brand variants assessed in the survey fully complied with the pictorial health warning requirement at all POS sites. Between 40-60% of brand variants were non-compliant (had no PHW at all), and 4-5% were partially compliant (had a PHW, but with other violations of the law such as excise stamps obscuring the warning on the packs). In addition to pictorial health warnings, information is also required on all packs to advise that there is “no safe level” of tobacco use and that cigarette smoke “contains more than 4,000 hazardous chemicals and more than 43 cancer-causing agents”. No domestic brands of the top five manufacturers provided this information.

Five of the largest tobacco companies, which collectively control 90% of the market, showed low compliance. Bentoel/British American Tobacco (BAT) was the worst offender, with non compliance between 63-90% in six of the survey sites. BAT had distributed a notice to retailers providing misleading information that production of packs with new PHW would only begin after June 24, and retailers can continue selling old stocks without a deadline. Even shops located right outside tobacco factories in Surabaya were selling packs without PHW.

The packs that did carry the new pictorial warnings created strong reactions from smokers, consistent with the evidence from other countries. The pattern was similar in all cities, with the most common reaction to look for packs with no PHW (52-96%), or choose the least scary picture – one which shows a “smoking man” with a skull background (68-95%).

In Makassar, more than 30% of smokers expressed feelings of disgust, fright, thoughts of buying single sticks, looking for non-PHW packs in other POS, no desire to smoke, perceived change in taste, and “accused” the industry of reducing the amount of cloves and flavouring in the cigarettes. The head of Gudang Garam distributors in Makassar had earlier expressed concern that the PHW had an impact and was seeing declining sales. Similar smoker responses were recorded in other survey sites.

Smokers negatively affected by PHWs resorted to several ways of obscuring pictures on packs, such as covering them with stickers showing attractive women, asking the shopkeeper for a dark tape to cover the PHW, putting the pack inside a case and even discarding the pack altogether in favour of alternatives. Sampoerna’s “A Mild” branded metal cases were found available for sale after June 24.

Such consumer reactions suggest that most Indonesian smokers previously were not fully aware of the many dangers of tobacco use. The strong reactions the PHW evoked are consistent with those of smokers everywhere, and provide positive feedback that PHW are effective, even among those heavily addicted. This explains why the tobacco industry strongly opposes PHW policy in Indonesia in the same ways it opposes effective tobacco control measures globally; first by filing a case in the Constitutional Court, then intentionally misinterpreting the effective date of implementation, and now delaying compliance even after the generous 20 months after the deadline for full implementation.

The Food and Drug Authority responsible for enforcement has given the industry ample time and warnings for compliance. It is time for the government to take serious action against the industry’s prolonged and continuing violations of the regulations which, if implemented properly, will set Indonesia on the path to reversing the epidemic for which the country pays such a high health, social and economic price.

Is it time to stop subsidising nicotine replacement therapies?

4 Feb, 15 | by Becky Freeman, Web Editor

By Simon Chapman, University of Sydney

Nicotine replacement therapy (NRT) became available in Australia in 1984 (gum) and 1993 (patches), first as prescription-only items. From 1988, they started becoming available as an over-the-counter item, with patches available without prescription from 1997. Today, some forms of NRT can even be bought in supermarkets.

If prescribed, NRT attracts a government subsidy. In the 17 months from July 2013 to Dec 2014, data provided by the Department of Health show 199,818 NRT scripts cost the government A$8,617,804.

But 31 years later, what should governments do if data show that NRT is little better, or even a good deal worse, at helping smokers quit than if they try to do it cold turkey?

Globally, the pharmaceutical industry understandably wants to convince quitters to use their products as much as possible. The smoking cessation field has long been dominated by research and promotional activity on how to deter smokers from ever attempting to quit without pharmacological or behavioural assistance, despite this being the way that most smokers have always quit.

Claims have abounded for years that NRT can significantly increase a smoker’s chance of quitting compared to placebo. These claims have overwhelmingly derived from clinical trials. But clinical trials differ markedly from real world use of NRT:

  • clinical trials exclude many people who might purchase NRT, such as those with any mental illness
  • there are major problems with blindness integrity (unsurprisingly, many smokers pickled in nicotine for years can guess if they have been allocated to the placebo arm of the trial)
  • trialists are contacted an average of 7.6 times by eager and supportive research staff trained to maximise retention of participants in the study
  • trialists are often paid for their participation
  • the drugs participants get are always free.

All this combines to produce an unreal situation and where trial participants do not represent all smokers and can be highly motivated to complete the trial to “please” the researchers.

So 31 years on, how does NRT perform away from clinical trials in the real world?

One of the world’s most rigorous and important data sets on smoking cessation comes from the Smoking in England study. A recent paper from that project casts a pall over any impact of NRT, other than generating more expensive urine in most of those who use it.

The paper reported on 1,560 English smokers who had made at least one recent and serious quit attempt. At six months, 23% were not smoking on the day they completed the questionnaire.

Several things stand out from this important study. First, smokers who used NRT obtained over the counter had by far the worst quit rate (15.4%) of any of the methods used. Even quitting unassisted (without using any medication or professional support), much denigrated by the makers of NRT and many smoking-cessation professionals, saw 24.2% taking this approach quit: a rate 57% higher than in those using NRT obtained over the counter.

The authors of the paper speculate that this low rate of success for NRT-users may be explained by “inappropriate usage and low adherence in the real world”.

Over the past three decades, NRT has been massively promoted via advertising and by pharmacists and doctors who have been heavily targeted by visiting sales reps. Doctors have been deluged with reprints of scientific articles on the virtues of NRT, and many have attended often lavishly catered educational meetings. Today, undying optimists still flying a flag for NRT still think there is hope that its users might one day start using NRT properly. Meanwhile, most who buy it keep smoking.

Second, the “most effective” method of quitting was also by far the least popular and acceptable. Using a prescribed medication (including NRT) and receiving specialised support for “at least six sessions” from one of England’s dedicated smoking cessation services saw 38.7% quit. But while the authors emphasised this throughout the paper, they were silent on how this best rate multiplied by the relatively small numbers availing themselves of these services would make much impression on the national goal of significantly boosting England’s quit rate at the population level. Any “most effective” way of quitting radically reduces in importance if few people are prepared to use it.

Only 4.8% of people attempting to quit were prepared to avail themselves of the “full monty” specialist cessation centres. These, even with the best success rate, contributed just 29 of the 359 who had quit using any method (8% of all quitters). This compared with 168 who had quit unassisted (a rate of 24.2%), yielding in this study nearly six times as many quitters as the specialist centres.

Third, having doctors write prescriptions for NRT or other prescribed cessation medications, and offering brief advice on quitting, produced a success rate only marginally higher than unassisted cessation (27.8% v 24.2%).

The fourth stand out message is what was not emphasised in the paper. If over-the-counter NRT (as it is mostly used), produces a far worse quit rate than smokers going cold turkey, where is the chorus of smoking cessation experts telegraphing this message to the community? How much worse would the data have to be before cessation experts declare its use-by date has arrived?

If the focus is on methods that yield high numbers of quitters throughout a population, this paper shows – as have many others – that cold turkey produced nearly 90% as many quitters (168) than from all other methods combined (191). Yet cold turkey is denigrated in pharmaceutical industry messaging like Pfizer’s “Don’t go cold turkey”.

The neglect of serious study of the way most smokers actually quit may be keeping us from gaining important insights that could be useful in campaign messaging.

Important questions also need to be asked about whether continuing the substantial government investment in subsidised-NRT is sensible. In the six months July to December 2012 (latest available data), the Commonwealth spent A$8.7m in media placement of anti-smoking messages trying to stimulate smokers to make quit attempts. How many more attempts might have been made had that figure been able to draw on the money being allocated to subsidised NRT?

Two studies of various Australian policies and programs’ impact on declining smoking prevalence between 1995 and 2011 found no evidence of impact of NRT sales or advertising volume.

Editor’s note: please ensure your comments are courteous and on-topic.

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