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Archive for September, 2017

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.

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