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Archive for April, 2015

Urgent action to amend Austria’s tobacco control laws

27 Apr, 15 | by Becky Freeman, Web Editor

Prof. Manfred Neuberger writes:

Since 2007 Austria has received the poorest score on the Tobacco Control Scale. While smoking prevalence and tobacco consumption decreased on average in the European Union, an opposite trend has occurred in Austria. Child smoking has increased dramatically since the 1990s. Cigarettes are available around the clock in thousands of vending machines, circumventing advertising bans and enabling easy access by children.

Legally, cigarettes can be bought at age 16, but half of 13-15 year olds smokers reported having bought cigarettes in tobacco shops. At age 15 already 18% of boys and 21% of girls are smoking daily. Tobacco shops are permitted to sell goods aimed at children and both indoor smoking and tobacco advertising is permitted. Tobacconists also distribute newspapers and are a powerful lobby group. Annual state revenues from cigarette consumption by minors in Austria exceeded 60 million €, but none of this revenue was budgeted for tobacco use prevention. With minor exceptions much of this work is left to unpaid volunteers (e.g. www.aerzteinitiative.at).

Children are permitted to enter smoking rooms and public smoking is visible to children as a normal adult behavior in most hospitality venues. While Austria ratified the WHO FCTC in 2005, it has had limited impact until now. Partial smoking bans were introduced in 2001 in workplaces and in public places in 2009 (with sanctions for violations), but this law is not well enforced. A further summary of the law and the associated problems can be read here.

littel girl smoking

Legally, cigarettes can be bought at age 16, but half of 13-15 year olds smokers reported having bought cigarettes in tobacco shops Piulet/flikr CC BY-NC-ND 2.0

The smoking ban in hospitality venues larger than 50m² provided the possibility of smoking rooms and the provisions that smoke should not leak into the nonsmoking areas was infringed regularly. Other violations of the partial smoking ban in the hospitality industry had to be reported by customers and were treated with long delays by local municipalities, a time-consuming method to enforce the law and frequently unsuccessful, even if taken to court.

Because partial smoking bans have failed, amendments to the tobacco law were prepared by the government, foreseeing a total ban in all schools (up to now in compulsory schools only), in the hospitality industry (including clubs, tents, multipurpose rooms), in hotels (except for smoking rooms, which must not serve for eating, drinking or sleeping), in all commercial transportation, and in tobacco shops used for mailing and other purposes, which still need to be specified. Use of water pipes or electronic cigarettes will also be banned where smoking is forbidden.

Crucial elements still missing from the legislation are: technical specifications for smoking rooms, such as a clear definition of their use for smoking only, clarification that the smoking ban applies to all rooms of hospitality venues (including kitchen, corridors, etc.), a ban on smoking and tobacco advertising in all shops and rooms accessible to minors, and a smoking ban in hospitals, on children’s playgrounds and in private cars carrying children.

The EU Tobacco Product Directive still needs to be included in the draft Austrian legislation and necessitates that the law enters into force in May 2016. The present plan to postpone this date until May 2018 is irresponsible and demonstrates the weakness of the government against the chamber of commerce.

The worst omission of the new Austrian draft is the lack of improvement in implementation and enforcement of the law. The present system of reporting violations by customers has failed, especially in small communities with only one inn where filing a complaint would be too personally risky. For example, some people who reported local innkeepers were pictured on a “wanted poster” at the entrance of the inn and were then forbidden to reenter.

Officials who were sent to venues for inspections only after customer complaint, could downplay the offence or postpone the decision by up to 28 months. During this time no other complaint about the same venue would be investigated.

It appears that this ineffective enforcement system will be continued. The draft law only names work inspection and food inspection as additional possibilities for control, but only during routine visits done for other purposes, and in the case of serious offences. Additionally, the draft law states that these controls must not incur extra costs. It is doubtful that rare and announced controls by such inspectors will improve the already poor compliance. Improving compliance for the better may require police assistance, as they could make unannounced controls during busy periods, such as at night in discotheques and other venues where young people meet.

Comments on the draft legislation are accepted until May 8th, 2015 at the ministry of health <leg.tavi@bmg.gv.at>, the ministry of finance <e-recht@bmf.gv.at> and the parliament <begutachtungsverfahren@parlinkom.gv.at>

Reuters reports U.S. to roll back ‘lost pleasure’ approach on health rules

20 Apr, 15 | by Becky Freeman, Web Editor

(Reuters) – The U.S. government is preparing to roll back a widely criticized approach to public health, in which the “lost pleasure” people might suffer if they quit smoking or chose to eat healthier foods was used to reduce the projected benefits of new regulations, government officials told Reuters.

Kenneth Warner, a University of Michigan economist who participated in the HHS working group, said it was incorrect to apply lost consumer surplus to an addictive behavior such as smoking. The vast majority of smokers say they regret having started and wish they could quit, he noted, so they would experience more satisfaction, not less, if they did so.

“The traditional understanding of consumer surplus assumes a rational consumer, and that becomes strange for a behavior that you start in adolescence or that’s addictive,” said Harvard economist Joseph Newhouse, also a working-group participant.

In the case of calorie counts, the lost-enjoyment analysis doesn’t account for the pleasure consumers may get from making healthier choices, such as enjoying a sense of virtue, or shedding enough pounds to wear a favorite pair of jeans again.

“That’s just not in the (FDA) analysis, and it should be,” said Warner.

The full Reuters article can be read here.

Tobacco Control recently published a related academic critique and editorial of the FDA’s analysis of the costs and benefits of the graphic warning label regulation on tobacco products. Perhaps this cartoon best captures the ludicrous notion that the pleasure of smoking offsets the costs by 70%.

The 16th World Conference on Tobacco or Health: Not exactly “World”

3 Apr, 15 | by Marita Hefler, News Editor

Wasim Maziak

Robert Stempel College of Public Health and Social Work, Florida International University, Miami, Florida

Two years ago, I was invited to serve on the scientific committee for the 16th World Conference for Tobacco or Health (WCTOH). I was particularly happy to serve, since this was the first time such an important event was planned in the Middle East, where most of my career has been focused. Over the past decade, several colleagues and I were greatly involved in initiatives aiming at seeding tobacco control research and training of tobacco control professionals from the region, with support from the US National Institute of Health.

The decision to hold the 16th WCTOH in Abu Dhabi (UAE) was only good news for me; a homecoming of years of efforts to seed science and evidence-based tobacco control principles in the Middle East. To build momentum, we started planning events that combine research and capacity building for tobacco control in the region, with conferences held in Abu Dhabi in 2013 and Qatar in 2014. We supported regional researchers to attend these conferences and conducted special research training workshops for junior researchers from the Middle East. This was complemented by a seed-grant program, for pilot studies in tobacco control in different countries in the region. Given the great opportunity presented by WCTOH for those grantees, we organized a special symposium during the WCTOH for our seed grantees to present their research results. This was really going well all around, and personally I was looking forward to a highlight of my career efforts in the region.

My excitement withered as the conference drew closer, when I started receiving worried messages from researchers in the region about a delay in their visa and travel arrangements. It became clear certain countries, not individuals, were the focus of visa denials. These were Syria, Iraq, Tunisia, and Bangladesh. I had a flashback from a year earlier, as I and my wife preparing for the 2014 waterpipe conference in Abu Dhabi, when her visa was denied while I had no problem. My wife is a tobacco control researcher from the University of Miami, and has years of work in tobacco control in the region. The only difference between us is that I had couple of months before received my new US citizenship, while she was still a permanent residence awaiting her citizenship and had to travel with her Syrian passport. When I brought this issue to the attention of one of the WCTOH organizers and warned about its grave potential for the WCTOH, he kept brushing the issue aside as of no concern.

Eventually, about 60 conference participants were denied entry to UAE, including 3 out of 6 participants in my symposium for young researchers in the region (Syria, Iraq, Tunisia). The conference organizers issued a statement that such denial is to be expected, and that it is actually less than previous similar occasions. However, I expect that in most similar occasions in the past visa denial was based on a case by case consideration not nationality, since I travelled to all of them since 2000 on my “cursed” Syrian passport. Still, I would have accepted this as related to the country’s policy with little that one can do about it. The main problem here is that the policy was well known to the local organizers based on previous experience, such as mine, but it was kept hidden from both the international organizing committee and conference participants. In the words of one of the conference Chairs, the local organizers assured everybody that “bona fide delegates would be allowed to enter the country”.

The largest delegation denied visas came from Bangladesh, one of the most active countries in Asia in tobacco control. It is also the home of second largest migrant working population in UAE, and has a lot to do with the construction and development boom of UAE, mostly under appalling conditions. What is worse is that the local organizers kept all participants from “shady” countries waiting even as the conference started (sometimes spending more than a day in the airport or with friends waiting for news) without telling them to go home based on what they knew of the extreme unlikelihood that they will receive a visa. Even two weeks after the conference, no official apology or responsibility declaration has been issued by any of the bodies related to the organization of WCTOH. This is unheard of from a community like ours that aspires to the highest moral values and respect for human dignity.

Tobacco control has been the cause of my life and career. Having a strong tobacco control community and successful international gatherings is vital for international cooperation and collaboration. If we remain silent about such mishandlings we risk repeating them or becoming accomplices in them. This is why I think such an incident requires a clear response from the organizers, and calls on us as community to create a better process for selecting host countries and organizing future World Conferences. Much more say in such decisions should be given to tobacco control activists from developing countries, who are at most risk of being refused visas, to ensure they have the opportunity for full participation.

World Conference on Tobacco or Health: keeping the focus on the tobacco industry

1 Apr, 15 | by Marita Hefler, News Editor

 

Anna Nicholson, Menzies School of Health Research

Follow Anna on Twitter @annaknicholson

The 16th World Conference on Tobacco or Health (WCTOH) was held in Abu Dhabi from March 17-21 2015, the first time it has been held in the Middle East. While this did not come without challenges (approximately 60 delegates, the majority from Bangladesh, were denied visas – see http://blogs.bmj.com/tc/2015/03/17/15th-world-conference-on-tobacco-or-health-regional-delegates-refused-visas/), the conference was attended by 2,184 delegates from over 100 countries. In the opening plenary, Dr Margaret Chan, Director General of the World Health Organization (WHO), rallied delegates to “keep the battle lines fresh and vigorous”, setting the tone for a program that focused on curtailing the tobacco industry. Despite many successes, delegates were sobered by the record profits recorded by a number of tobacco companies since the 15th WCTOH in 2012, notably in low income countries.

It is 10 years since the WHO FCTC came into force. So where are we now? Of the 178 countries with available data, about two thirds (125) show declining prevalence, but fewer than one in five (37) countries are on track to meet a 30% reduction by 2025. Country-specific surveillance shows 45 countries have comprehensive smoke free policies, 21 have adequate cessation support, 30 have graphic warning labels (>50% of pack), 24 have total advertising & promotion bans, and 32 have adequate taxation (75% of retail price). Day one of the scientific program focussed on growing evidence of the role of MPOWER, the technical package of technical measures and resources to achieve demand reduction provisions of the FCTC (Monitor tobacco use and prevention policies; Protect people from tobacco smoke, Offer help to quit tobacco use, Warn about the dangers of tobacco, Enforce bans on tobacco advertising, promotion and sponsorship, Raise taxes on tobacco).

The conference theme was ‘Tobacco and Non-Communicable Diseases’ (NCDs). It was refreshing to be reminded of the importance to think beyond tobacco, and hear shared learnings from countering food, beverage and alcohol marketing. Delegates were urged to consider strategies that shift responsibility from the individual to industry and government, including product regulation, hard-hitting and sustained campaigns that raise public awareness, and advertising, promotion and sponsorship bans. Underpinning discussions was an awareness that funding available for preventing cardiovascular and other non-communicable diseases is in no way reflective of the scale of the NCD epidemic. Delegates heard about progress toward the World Health Assembly target to reduce tobacco use by 30% as part of the 25×25 global target of a 25% reduction in NCD deaths by 2025, and advocacy efforts to integrate the FCTC with the UN Sustainable Development Goals (SDGs).

The social, economic and environmental impacts of the tobacco industry were also acknowledged: issues such as food and water insecurity, air pollution, deforestation and pesticide use, as well as trade, farming and poverty. Delegates were urged to speak out against these tobacco-related inequalities. A number of symposia featured the heavy burden on low and middle income countries, with a particular focus on ‘best buy’ tobacco control strategies.

Attention was also drawn to many countries failing to provide adequate financial resources to tackle implementation of the FCTC (including high income countries), and the importance of keeping tobacco control efforts free of industry funding and influence. At a national level, delegates heard of the importance of strengthening primary health care systems, improving alliances, and advancing the role of these systems as agents for social change. The role and importance of civil society was also acknowledged, and delegates were encouraged to extend their partnerships and role as tobacco control advocates by including new champions for health reform.

Plain packaging was the focus of one plenary and a number of symposia. Nathan Smyth from the Australian Department of Health welcomed Ireland and the UK, which have both recently voted to introduce plain packaging, to “the greatest fight on Earth”. There was much discussion of lessons learned from current legal battles against the tobacco industry, which aims to slow the diffusion of plain packs by tying up resources, increasing the costs, and countering the evidence base. It was heartening to see the growing number of nations who have plain packaging in their sights despite these battles.

Lack of an evidence base was a key argument the tobacco industry used to fight Australia when it became the first country to introduce plain packs in 2012. Professor Melanie Wakefield used the analogy of a train leaving the station, collecting evidence from stops en route to the destination of reduced prevalence. Hot off the press of the April 2015 Tobacco Control supplement on plain packs, Professor Wakefield, Dr Michelle Scollo and other Australian researchers shared their ‘en route’ findings of the benefits of plain packs to reduce appeal and brand differentiation, focus attention on warning labels and reduce the ability to mislead consumers. Several presentations discussed the influence of pack shape and branding on consumer interpretations of attractiveness and harm, particularly for slim varieties, further highlighting the usefulness of standardised packaging. Delegates were also reminded of the synergistic effects of policies. Plain packs are not a magic bullet; rather they work together with complementary policies such as total bans on other forms of tobacco industry advertising and promotion. (For more about the supplement and the implications of the research findings, see http://blogs.bmj.com/tc/2015/03/18/blockbuster-special-issue-evaluation-of-the-australian-tobacco-plain-packaging-policy/).

Perhaps the most divisive debate was whether e-cigarettes should be viewed as a friend or foe of tobacco control. While the WHO urged caution, presenters in other symposia challenged the need for tight regulation, arguing this may stifle the emergence of potentially safer technologies. Experts appeared unanimous in their agreement that e-cigarettes produce metabolites known to cause disease such as lung cancer, emphysema, pulmonary fibrosis and cardiovascular events. However, the harm is greatly reduced compared to combustible cigarettes, and may be reduced further in new generations of e-cigarettes, particularly if new technologies can eliminate heating altogether. Delegates learned that some youth are using e-cigarettes before smoking cigarettes; however, no strong evidence of a “gateway effect” was reported. Nonetheless, delegates and presenters voiced concern over the appeal of flavours, the need to ban sales to minors, and the need to monitor effects of vaping in public. Given that e-cigarettes are an increasingly popular form of cessation assistance, the issue of how to best regulate them presents a pressing challenge. Professor Ken Warner reminded delegates to keep the focus on evidence-based tobacco control, look to more enlightened regulation (that does not discourage innovation) and continue to reduce the attractiveness of combustible cigarettes.

After four days of stimulating science, the conference ended with a rousing vision from the youth pre-conference delegation on their campaign “No More Tobacco in the 21st Century” (#NMT21C on Twitter), the prioritisation of which featured in one of the conference resolutions. Other conference resolutions centred on the FCTC: increasing signatories, achieving its recognition in the SDGs, and targets towards additional specific measures. There were also resolutions to treat tobacco uniquely in trade agreements, strengthen the Protocol to Eliminate Illicit Trade in Tobacco Products, and for a UN high level meeting to address the threat to humanity caused by the tobacco industry. Interestingly, despite the discussions and presentations throughout the conference, other broad action on NCDs was not featured in the conference resolutions.

The conference closed with the announcement that South Africa had won the bid for the 17th WCTOH, the first time the conference will be hosted by an African nation. The challenge was set with the words of Nelson Mandela: “I have walked that long road to freedom. I have tried not to falter; I have made missteps along the way. But I have discovered the secret that after climbing a great hill, one only finds that there are many more hills to climb”.

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