JTI-Macdonald is one of Canada’s big three tobacco firms. On Saturday 17 September, it ran an ad in several of Canada’s leading newspapers to argue against tobacco plain packaging legislation, which the Canadian government is currently considering. The ad is shown here:
Advertisement by JTI-Macdonald against tobacco plain packaging in Canada
The ad may have been intended to argue against plain packaging, but by loading a cigarette pack with 20 bullets, the company has inadvertently reminded Canadians that the product it sells is actually a deadly weapon – a smoking gun, by an unconscionable industry’s own unconscious admission.
Despite tentative progress in recent years, Germany has historically been one of Europe’s poster children for tobacco control legislative failure. That reputation may begin to change from 20 May, when gory pictures of black lungs, dead bodies and other consequences of smoking will be plastered over two thirds of the surface area of cigarette packs, in line with European Union regulations.
Although some smoke free legislation is in place, lax advertising restrictions have allowed tobacco companies to continue to use advertising billboards in Germany – one of only two European countries which have not yet outlawed such a blatant violation of the FCTC. Even neighbouring Austria, the perennial ‘rogue state’ of European tobacco control, does not allow cigarette billboards.
According to the German Cancer Research Center, 121,000 people die from smoking-related causes each year, representing 13.5% of all deaths in Germany. There are significant regional variations in the country, with the percentage of smoking-related deaths as high as 23% in some places.
The introduction of graphic health warnings signals a pivotal moment which it is hoped will be the beginning of serious tobacco control legislation and the inexorable decline of smoking in Germany.
Ranking of 34 European countries in 2013 according to the Tobacco Control Scale. See http://www.europeancancerleagues.org/images/TobaccoControl/TCS_2013_in_Europe_13-03-14_final_1.pdf
A series of emotional and hard-hitting television ads have been launched in the UK to tell the stories of real former smokers who have been affected by cancer. The ads detail the trauma of diagnosis, the harrowing treatments that they endured and the emotional and physical toll in their lives.
Maggie, a 60 year old former heavy smoker who was diagnosed with mouth cancer when she was 45, says “never in a million years did I think I would get cancer…I never thought for one moment it would be me”. In order to remove the cancer, she had to have one side of her mouth removed and now needs to wear an obturator – a prosthesis in her mouth with false teeth and a piece to replace the roof of her mouth – which allows her to eat and talk.
The ‘16’ in the campaign refers to 16 types of cancers that can be caused by smoking. It aims to raise awareness about some of the lesser-known health impacts among smokers, and inspire them to quit to reduce their risk of developing smoking-related cancers. As Maggie says in the video, although she knew about lung cancer, she had never heard of mouth cancer. She discusses understanding that people enjoy a cigarette, and she did too, but “when I look back at what I had to go through, was it worth it? No. Definitely not.”
Tony, a 55 year old who had to have much of the inside of his neck removed when he was diagnosed with laryngeal cancer talks about how he used to spend a lot of time swimming “but now I can’t because if water does get in there, it’s just straight into the lungs….it’s affected all my life. Everything I used to do, I can’t do anymore.”
Department of Community Health Sciences, Patan Academy of Health Sciences, Lalitpur
It has been four years since the Tobacco Product Control and Regulatory Bill was passed in Nepal and significant progress has been made since then. The decision by the Nepalese government to increase the surface area of all tobacco packaging with graphic warnings against tobacco from 75% to 90% was commended globally. Despite stronger legislation, implementation has been slow. More is needed to reduce the growing burden of Non Communicable Diseases (NCDs) in the country.
Nepal has made significant progress towards tobacco control in the last decade. It became a signatory to the WHO Framework Convention on Tobacco Control (FCTC) in 2003, and ratified it in 2006. In what was regarded as the landmark in the nation’s campaign against tobacco, the Constituent Assembly approved the Tobacco Product Control and Regulatory Bill 2010 on April 11, 2011. Major features of the new law included a complete ban on smoking in public places, workplaces and public transportation. It also banned the sale of individual cigarettes, prohibited unlicensed vendors from selling tobacco products, deemed tobacco sales to minors (under 18 years of age) and pregnant women as offenses, and required tobacco companies to cover 75% of cigarette and other tobacco product packaging space with pictorial health warnings. It also introduced a health tax on tobacco products, and a total ban on tobacco advertisements, promotion and sponsorship in any form. The law supported the provision of punishments and penalties for violation of these new regulations.
Recently Nepal took another significant step by increasing the surface area of all tobacco packaging with graphic warnings to 90% of the pack. Pictorial health warnings are a particularly important deterrent against smoking among people with low literacy and younger generation. The legislation was due to be implemented by all the tobacco companies in Nepal from May 2015, and would mean Nepal has the strongest tobacco warnings after Australia, where plain packaging legislation has been in place since 2012. In recognition of this achievement, the Ministry of Health and Population of Nepal was awarded the 2015 Bloomberg Philanthropies Award for Global Tobacco Control at the 16th World Conference on Tobacco or Health held in Abu Dhabi, U.A.E. in March 2015.
The clear violations identified by these small scale studies raise the question of how effectively the anti-tobacco law is really being implemented. Another issue of concern is the rising prevalence of female tobacco use in Nepal, and the fact that Nepal has the highest female smoking prevalence among nine Southeast Asian countries.
Most high income countries have been able to combat the tobacco epidemic with strict regulations. Nepal is well on the way, aiming for a 25% reduction in the relative mortality from NCDs by 2025 (the 25 by 25 goal). Effective implementation of the anti-tobacco law is urgently needed to ensure this is achieved.
Comparing meat to tobacco, as most news organisations who’ve chosen to report this have done, makes it seem like a bacon sandwich might be just as harmful as a cigarette. This is absolutely not the case.
This Cancer Research UK infographic elegantly shows that while the evidence that processed meat causes cancer is as strong as for tobacco, the RISK from smoking is so much higher:
(click to enlarge image)
This post has Comments Off on The problem with comparing meat and smoking cancer risk.
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.
This story should be required reading for anyone who works for a tobacco company or denies that tobacco causes horrific suffering. The editorial team at Tobacco Control thanks Karen for her bravery and honesty in sharing her very personal story.
Beyond statistics: the hidden face of smoking-related cancer
The Russian dictator Joseph Stalin infamously said that a single death is a tragedy, a million deaths a statistic. And in tobacco control, there are statistics to die for. Tobacco caused about 100 million deaths last century. But a projected one billion people will die from tobacco-caused disease this century if present trends continue.
The average smoker takes 12.7 puffs per cigarette. A person who starts smoking at age 15, and smokes 20 cigarettes a day for 40 years, will baste the delicate pink linings of their mouth, throat and lungs with a cocktail of 69 carcinogens 3,710,940 times by the time they reach just 55.
Half of long-term smokers die early from a tobacco caused disease, taking an average of ten years off the normal life expectancy. A cigarette takes about six minutes to smoke. So for every cigarette that a person like former Beatle George Harrison – who died from lung cancer at 58 – smoked, they lost more than five times the time it took to smoke them, off the end of their life.
On and on it goes, but statistics on tobacco deaths have become banal for many. People rationalise that life’s a jungle of risks, that feeling fine or seeing longevity in a smoking relative means that they are bullet-proof, and cling to self-exempting beliefs like air pollution causes most lung cancer or that putting on some weight if they quit is more dangerous than smoking.
What is so often missing from these reflections about smoking is any real appreciation of the suffering and greatly diminished quality of life or the years that people can spend living with smoking caused disease.
On many occasions across my career I’ve received unsolicited letters, calls and email from people living with tobacco caused disease. Two in particular stand out.
An articulate 52 year old woman called me a few years ago. Give the “smoking kills” line a rest, she urged:
I’ve smoked for thirty years. I have emphysema. I am virtually housebound. I get exhausted walking more than a few metres. I have urinary incontinence, and because I can’t move quickly to the toilet, I wet myself and smell.
I can’t bear the embarrassment, so I stay isolated at home. Smoking has ruined my life. You should start telling people about the living hell smoking causes while you’re still alive, not just that it kills you.
Then last week, amid publicity on the 50th anniversary of the first historic United States Surgeon General’s report on smoking, an amazingly brave woman, Karen Daniels, wrote to me. Her words moved me to tears and with her permission, you can read them below.
Smoking tobacco causes around 70% of oral and pharyngeal cancers in men, and around 55% in women. In Australia in 2009, 3031 Australian were diagnosed with various head and neck cancers, and in 2010, 1,045 died.
This cancer is brutal! Treatments are cruel! Daily for six to eight weeks during radiotherapy treatments our head and face is covered with a tight mask and bolted to a slab while radiotherapy is blasted at our mouth teeth jaw face and neck. Damage during and after this treatment is horrendous. Many of us will never speak clearly, swallow or function normally again.
Patients endure tracheotomies inserted in their wind pipe because we cannot breath naturally through our mouth and nose due to swelling and other side effects.
Many people are left with PEG feeding tubes shoved in their stomach for the rest of their lives because they will never swallow normal food via their mouth again. I had a PEG tube for three and a half years. A tube hanging from our stomach is sickening and depressing. Think about never eating another meal or swallowing again! You can’t imagine the never ending physical and emotional hell this particular disease causes.
I was diagnosed in 2007 at 46 years of age. Yes, I smoked for several years. I have endured 12 surgeries since 2007 trying to improve my quality of life.
Almost all my entire tongue, lower jaw, gums and beautiful teeth have been removed and reconstructed because of treatments to remove cancer. Bone was taken from my hip to reconstruct my jaw. Normal function is gone… Permanently. My perfect face is now disfigured.
I have not sat down to a normal meal with friends or family in almost seven years. Those pleasures of socialising, eating at restaurants and dinner parties that everyone regularly attends are history for us. I struggle to control saliva because of oral cavity nerve damage and facial trauma. Sometimes I dribble when I try to speak. I will never kiss again.
My life has been destroyed by this cancer, as has many other wonderful people around Australia. We lose our careers. Relationships fall apart.
We can’t make appointments over the telephone or ask for something over a counter. No one can understand us! We write down questions during appointments because we can’t speak and Doctors don’t understand what we’re saying. That doesn’t work! This is frustrating, humiliating and extremely upsetting.
The aftermath from this disease is debilitating and permanent. Dental issues are painful and relentless, yet the previous Federal Government abolished the Enhanced Care Dental Scheme. This is shameful!
We can’t just pick-up from where we left off. We can’t “do coffee” with friends and chat about our issues like most other cancer patients because we can’t speak or drink as normal. We can’t cover our mouth with a piece of clothing and get on with it. Our face is our identity!
Many smokers say things like “oh well, I’m going to die anyway” or “I could get hit by a bus tomorrow”. Well, from my experience I can honestly say dying immediately would be much easier than the long slow suffering this disease puts patients through. In 2007 while in hospital I had a cardiac arrest because the tracheotomy blocked. Once resuscitated, little did I know I had years and years of pain, ongoing treatments and loss of normal function ahead of me! It’s devastating!
My lower face and mouth has been cut and shut many times. My neck/throat has been dissected twice ear to ear. It’s been a long difficult road! I’ve undergone six surgeries in the past three years trying to improve mouth function and facial appearance. More than likely there’s a few more down the track. I have a wonderful plastic surgeon who genuinely cares!
Karen’s hopes are for more resources to be given to care and support for people like herself. I hope her story stimulates far greater attention to some of the cancers like hers that do not enjoy the publicity of some of the higher profile cancers.
But with so much potential for head and neck cancers to be prevented, I hope too that her unforgettable words will be passed along to anyone still smoking.
Simon Chapman does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
Update: On 1 August, 140 youth and students held a protest rally at the World Trade Centre in Bangkok, location of the Philip Morris International offices, to show support for 85% pictorial warnings, and to symbolise “140 deaths from tobacco use every day” in the country.
To: Manager of Philip Morris International (Thailand) Limited and Manager of Japan Tobacco International (Thailand) Limited
Subject: Request to withdraw the lawsuit against Ministry of Public Health on the regulation requiring 85% pictorial health warning on cigarette packages
Due to the lawsuit filed by your company against Ministry of Public Health Thailand on the case of 85% pictorial health warning on cigarette packages regulation at the Administrative Court, we, Youth Network in Thailand, would like to request you to withdraw this current lawsuit against Ministry of Public Health Thailand.
We are well aware that you have great concern of decreased cigarette sales volume as a result of 85% pictorial health warning regulation. This is because the new warning will provide clearer facts to consumers. In particular, it will raise awareness on Thai children and youth, who are your targets, not to initiate smoking. You should be fully aware that in 2011, there are already 2,200,000 Thai children and youth who are your current customers, not to include 10 million of adult customers. Your company will continue to gain major profit from them in many decades.
You may need to ask yourself whether your effort to avoid compliance to Thai domestic law by filing the lawsuit against Ministry of Public Health, in order to increase sales volume of your products by attracting more children and youth to become your customers in the replacement of those who already died or in illness, is ethical practice.
We believe that you have enough expertise to initiate other business that benefits children and youth development including your own children. Youth always welcome new innovation but not for cigarettes that kill its consumers.
On behalf of the youth network, we would like to request you to withdraw the lawsuit against Ministry of Public Health Thailand on the case of 85% pictorial health warning on cigarette packages regulation, and request you to comply with the Tobacco Control Law of Thailand.
On behalf of the organizations as below:
Pak Dee Gang youth network,
Youth Network of Bangkok,
Youth Council of Satorn, Bangrak, Rajathevi, Watana, South Bangkok
Pharmacy Students ‘Union of Thailand,
Ya Mo Student in Public Health
Public Health and Health Sciences Students Association of Thailand,
Public health student, Network of Health Education and Behavioral Sciences Faculty Public Health Mahidol University,
Young Filmmakers of Thailand, Fongnom FILMS,
Network of Non Smoking generation /Teachers Networking for Smoke-Free Schools
The World Health Organisation Report on the Global Tobacco Epidemic 2013 was launched in Panama City on 10 July. Panama was selected as the venue for this high level, global event in recognition of the country’s leadership in tobacco control.
The report shows the number of people worldwide covered by at least one life-saving measure to limit tobacco use has more than doubled in the last five years. Three billion people are now covered by national anti-tobacco campaigns. Other highlights include:
The number of people covered by tobacco advertising, promotion and sponsorship (TAPS) bans, the focus of this year’s report, increased by almost 400 million people, the majority of whom reside in low and middle-income countries.
24 countries with 694 million people have introduced complete TAPS bans. However, 67 countries currently do not ban any TAPS activities, or have a ban that excludes advertising in national broadcast and print media.
Effective health warning labels on tobacco packaging continue to be established by more countries. In the past five years, a total of 20 countries with 657 million people put strong warning label requirements in place.
More than half a billion people in nine countries have gained access to appropriate cessation services in the past five years. However, there has been little progress since 2010, as only four additional countries with a combined population of 85 million were newly provided access to cost-covered services including a toll-free national quit line.
Creation of smoke-free public places and workplaces continues to be the most commonly established measure at the highest level of achievement. 32 countries have passed complete smoking bans covering all work places, public places and public transportation means between 2007 and 2012, protecting nearly 900 million additional people.
Nearly 3.8 billion people (54% of the world’s population) live in a country that has aired at least one national anti-tobacco mass media campaign on TV and/or radio for a duration of at least three weeks in the past two years.
The report is the fourth in a series by WHO on MPOWER measures – the six evidence-based tobacco control measures that are the most effective in reducing tobacco use. (Monitor tobacco use and prevention policies, Protect people from tobacco smoke, Offer help to quit tobacco use, Warn people about the dangers of tobacco, Enforce bans on tobacco advertising, promotion and sponsorship, and Raise taxes on tobacco