Mary Assunta
Southeast Asia Tobacco Control Alliance

Marlboro Black Menthol billboard in Timor-Leste, 2013
Photo: George Darroch

At its annual shareholder meeting in New York on 8 May, Philip Morris International (PMI) celebrated yet another successful year selling tobacco in more than 180 markets. In 2012 the company shipped 927 billion cigarettes, and earned revenue of more than $31 billion. It applauded the fact its sales, especially from emerging markets (euphemism for developing countries), had increased from 53% in 2007 to 61% in 2012. PMI claimed it had an estimated 16.3% share of the total international cigarette market outside of the USA (see the annual report here).

The American cowboy continues to make mega profits from the developing world, even from new, small countries like Timor-Leste in Southeast Asia. Timor-Leste ranks low on the Human Development Index at 134 out of 186 countries. Its GDP is $1.6b and 50% of its population live below the poverty line, with about 40% experiencing severe poverty. About 37% of its people earn US$1.25 a day.

To add to its challenges, it has a growing smoking problem. One third of adult men smoke, while an alarming 50% of teenage boys (13-15 years) and 17% of teenage girls smoke. A pack of cigarettes cost $1.00, and a Global Youth Tobacco Survey study showed 35% of all teenagers have an object with a tobacco logo on it.

Misleading descriptors on cigarette packs have been prohibited in the US since 2006, when tobacco companies lost a case brought against them under the Racketeer Influenced and Corrupt Organizations Act (RICO). However, outside the US, PMI continues to sell cigarettes with misleading claims such as ‘fresh’ and ‘gold touch’. PMI launched Marlboro Black Menthol in Asia in 2008, including in Indonesia, Malaysia, Philippines and Japan, promoting it as a “fresh taste sensation”. In 2009 Marlboro Black Menthol brand sold four billion units in Asia. PMI claimed each new introduction has a positive impact on the vibrancy of the brand across a wide range of markets through “a very positive ‘halo’ effect on the whole brand family.”

With high male smoking prevalence, Asia is a key PMI target region; between 2007 and 2012, its market share grew from 25% to 35%. It has identified several countries as exciting growth opportunities especially Indonesia, Philippines, Vietnam, Thailand, Korea and Bangladesh. Marlboro cigarettes are positioned as a key driver of growth, together with local brands such as A-Mild in Indonesia and Fortune in the Philippines.

PMI’s strategy to introduce several brand extensions of Marlboro such as Flavour Filter Plus, Gold Touch and Fresh capsule has enabled the company to sell 179 billion extra sticks, equivalent to 6% of its sales. The WHO Framework Convention on Tobacco Control (FCTC) Article 9 calls upon countries to regulate tobacco products specifically to address these types of extensions.

With an eye on the 750 billion sticks currently sold by state-owned monopolies, PMI has slated partnerships with these as the way forward to tap into markets. In Vietnam, through a partnership with Vinataba to produce Marlboro cigarettes, PMI is already seeing increases in Marlboro sales from 0.5% in 2009 to 2.8% of total sales in 2012. Vietnam has just passed comprehensive tobacco control legislation that bans tobacco advertising and promotions and requires 50% pictorial health warnings on cigarette packs, however strict implementation is needed and all loopholes plugged to arrest increasing cigarette sales.

The tobacco industry has shown it will aggressively pursue market expansion, frequently profiting even where poverty rates are high. Its sales are increasing. However as long as the tobacco industry is viewed “like any other business” by departments of trade, it will continue to milk its status as an investor and enjoy a thriving business. The industry is using the trade platform and bilateral investment agreements to challenge governments such as Uruguay and Australia who take stringent measures like prominent health warnings and plain packaging to protect public health.

Developing countries do not have the necessary resources to defend their public health measures in expensive, prolonged arbitrations. Tobacco cannot have the privileges (Article 5.3 Guidelines) accorded to other businesses and it cannot be treated like a normal product on the trade platform.

Rosanne Palmer

Ash Wales/Ash Cymru

Editors note: this is an update to a blog post published on 3 May about a proposed amendment to Wales’ smoke free legislation to allow cast members to smoke on film and television sets.

The Welsh Government announced on 15 May that the proposals were being dropped. This move followed a review of the evidence submitted to the National Assembly for Wales’ inquiry into the amendment by the two principal ministers concerned – Mark Drakeford, Minister for Health and Social Services and Edwina Hart, Minister for Economy, Science and Transport.

Whilst the timing of the move was unexpected, it was clear from his time as Chair of the Health and Social Services Committee that Professor Drakeford was resolutely opposed to the amendment, a stance that he maintained when appointed as Health Minister in March this year. It has been suggested that, in addition to opposition from health organisations, including the British Medical Association and the Royal College of Physicians, there was weak support for the amendment amongst Assembly Members (AMs). Given that the two ministers themselves were due to give evidence on 12 June, perhaps the timing is not so surprising after all.

Throughout the campaign, social media channels were used as a medium for maintaining pressure in opposition to the proposal, in particular the use of an on-line petition and the use of Twitter to both spread the message and communicate with important actors involved in the debate. Of particular note were the activities of the Chartered Society of Physiotherapists in Wales in writing to AMs as well as other members of the Wales Tobacco Control Alliance in opposing the proposed amendment.

The same announcement also confirmed that the Welsh Minister for Health and Social Services had written to the UK Secretary of State for Health, Jeremy Hunt, supporting the introduction of legislation on standardised packaging.

Author credit: Marita Hefler and Stan Shatenstein

On 2 May, the Sun newspaper reported that the UK government had decided to abandon cigarette plain packaging legislation. An announcement about the legislation had been widely tipped to be included in the Queen’s speech at the start of the next parliamentary session on 8 May.

No other media outlets initially reported the decision to drop the policy, leading to confusion about whether the report was correct. However, in the face of a surge of support for the tobacco-friendly UK Independence Party (UKIP) and tobacco industry pressure, it appears that the government has decided to put the tobacco lobby ahead of public health.

Jamie Doward in The Guardian reports that the move comes after tobacco industry representatives met with health department officials and threatened that the plan would result in thousands of jobs going abroad. Details reported in the article of the industry’s campaign against the proposal show it took lessons from the failed Australian campaign, and was in part masterminded by Australian lobbyist Lynton Crosby, who has close ties with Australia’s conservative opposition Liberal Party. While the measure will still be implemented in Scotland, dropping it elsewhere in the UK is likely to be divisive with the government, as the Liberal Democrats are strong supporters of plain packaging.

Other coverage of the decision has been justifiably scathing:

“The tobacco industry argues that there is no evidence that plain packs discourage young people from starting to smoke. But inspection of tobacco industry documents released as a result of lawsuits reveals that the industry has been preparing for the battle for at least a quarter of a century. It will deny it, but the tobacco industry understands how brands lure in young smokers. It needs this new generation to replace the older one that it is killing. The UK government has a mandate to improve the health of its citizens. Last week, it failed them.” [Editorial. Smoking: the government's cowardly surrender to the tobacco lobby, The Observer]

“I don’t blame the tobacco firms. Death is their business. When BAT says, after exhausting its arguments, that “We will take every action possible to protect our brands, the rights of our companies to compete as legitimate commercial businesses selling a legal product, and the interests of our shareholders”, I almost admire its dedication to cash. Yet the British government, theoretically dedicated to the health of its citizens, has a duty not to sink to lobbyists… It attacks the habits of the poor, but does nothing helpful. As ever with this government, hollow rhetoric will do.” [Tanya Gold, Death is tobacco companies' business, The Guardian]

“The statement, attributed to a Whitehall source, describing plain packaging as “nothing to do with the Government’s key purpose” is extraordinary. The health of the people is surely the highest purpose of government, so it is chilling to hear that the Coalition does not consider the prevention of ill health and premature mortality to be part of its role.” [Letter signed by 155 health professionals. Plain cigarette packets, The Telegraph]

Kosovo has surged ahead in tobacco control with the introduction of a comprehensive tobacco control law. Notable among the range of measures is the strongest protections against tobacco industry interference in the world, based on Article 5.3 of the WHO Framework Convention on Tobacco Control (FCTC). The measures, which will apply to the whole of government and be enforced by the national Anti-Corruption Agency, include:

• No unnecessary interactions between government and tobacco industry.
• Full transparency for necessary interactions.
• Prohibition on government partnership with, or support of, the tobacco industry.
• Prohibition on contributions from tobacco industry to government, to government officials, and to political parties.
• Strong tobacco-related conflict of interest provisions

The country already had a weak tobacco control law which was passed in 2007, but had been struggling to enforce it. With female smoking prevalence of 44% – the second highest in the world – and 47% of youth having tried smoking before turning 18, the new law is a welcome measure. Other provisions in the law are:

• 100% smoke-free indoor public places, work places, and public transportation, as well as specified outdoor areas, with some very minor exceptions.
• Comprehensive bans on tobacco advertising, promotion, and sponsorship, including a ban on retail tobacco product displays.
• Graphic health warnings on both sides of the pack.
• Ban on misleading packaging, including descriptors such as ‘light’ and ‘low’.
• Prohibition on sales to and by minors.
• Ban on sales in health, education, and athletic facilities.
• Granting power to the Ministry of Health authority to ban ingredients.
• Constituents and emissions limits with reporting requirements for manufacturers.
• Cessation and education measures, include 45 minutes each month of mandatory programming on public radio and television.

A fully open access supplement of Tobacco Control is now available. With 20 articles contributed by 27 authors it is rich with ideas and possibilities.

Dr Kenneth Warner sets the scene for this themed supplement:

In this supplement, some of the world’s most brilliant tobacco control scholars, strategists and activists, including those who originated the principal endgame concepts, offer a wide range of observations pertinent to contemplating the endgame. With other colleagues, these authors gathered together in Ann Arbor, Michigan, last June at a workshop hosted by the University of Michigan School of Public Health to contemplate the very notion of an endgame and to debate the merits of the various endgame proposals brought to light to date. The workshop was sponsored by grants from the American Legacy Foundation and the Robert Wood Johnson Foundation, who also sponsored the development and distribution of this supplement. On behalf of the workshop organisers and participants and the supplement authors, I express our deep gratitude to these visionary organisations for their willingness to encourage thinking outside the box.

The papers published in this volume are not the proceedings of the workshop, although they certainly reflect both the subject matter covered and the diversity of issues and perspectives that characterised the lively proceedings.

The goal of the workshop—and indeed the goal of this supplement—was never to produce a consensus on any of the challenging questions that pervade the subject of the tobacco endgame; it is far too early to do so. Rather, as one participant put it, the intent of the workshop was to serve as ‘an intellectual ice-breaker’ for the field of endgame studies. We hope this supplement will play a similar role for the broader tobacco control community, opening up the debate, enlisting a wider array of tobacco control and public health professionals, and thereby hastening the determination of answers to the challenging questions. While we struggle today with often widely divergent perspectives and beliefs, we all share the same vision of the final words to this story: ‘The end’.

Marisa de Andrade & Gerard Hastings

Institute for Social Marketing; University of Stirling

marisa.deandrade1@stir.ac.uk

Editor’s note: The United Kingdom’s health regulator, the Medicines and Healthcare products Regulatory Agency (MHRA), is currently considering how to regulate ecigarettes. Given that marketing of these e-cigarettes is of particular concern, Marisa de Andrade and Gerard Hastings were commissioned by Cancer Research UK to conduct a rapid review of current practices and emerging trends. Here they provide highlights from the review.

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Multiple brands of e-cigarettes are being widely marketed, both online and in conventional media, as safer, ‘healthier’ and cheaper alternatives to smoking that can be used either to quit, or for dual use in places where smoking is not allowed – thereby enabling smokers to ‘take back their freedom’.

The products come in various flavours, colours and innovative packaging and have been endorsed by celebrity doctors and actors as well as fictional cartoon characters; presented as ‘must-have’ accessories; linked to charities; featured in various television programmes and films and been pictured in the hands of celebrities.  The ads frequently use images of young, attractive men and women and, in one case, sponsor a 19 year old British Touring Car professional racing driver.  Much imaginative use is made of online marketing – including social networking platforms; online consumer forums and internet-affiliate schemes which turn users into sellers.

The advertising regulator – the Advertising Standards Authority – is struggling to tackle this plethora of marketing communication. It has taken steps to remove claims on e-cigarette websites suggesting that the products are harmless (this remains unproven), and is monitoring television advertising – which cannot, for instance, make reference to the act of smoking.  However, the regulatory challenges are significant.

Early efforts to regulate tobacco advertising showed how difficult it is to control the content of imagery-rich appeals; thus the fact that smoking cannot be directly mentioned does not mean that it is not being indirectly invoked using pictures or associations.  Even with the best intentions, transgressions slip through the net; for example many e-cigarettes are being promoted as smoking cessation aids although they are not currently licensed for this in the UK.  Furthermore, online publicity presents particular difficulties – websites can be set up outside UK jurisdiction, for instance, and website age protection remains rudimentary.  The potential appeal of ecigarettes to the young is a particular concern, with at least one baseline study suggesting that younger, non-minority smokers with higher incomes have a high awareness of these products.

These developments have recently taken a more sinister turn because the tobacco industry has acquired large stakes in the e-cigarettes business.  As a corporation, a tobacco company’s overriding objective is to maximise profits. It is possible that this could be benefit public health by enabling them to diversify away from burned tobacco products, and so hasten the move to smokefree.  However, given the market size and dominance of burned tobacco, it seems more likely that these acquisitions will be used to bolster the status quo by normalising nicotine use, providing control of the recreational (and possibly pharmaceutical) gateways to it and turning a potential competitor into a product range (or even brand) extension.

The rapid review pinpoints two key areas of e-cigarettes which urgently need more research. Firstly, we have to know much more about public, and especially young people’s (including smokers and non-smokers), response to ecigarettes and the related marketing. To what extent are these developments modelling, reinforcing, or in any way promoting smoking? Secondly, it is vital that we learn much more about the tobacco industry’s intent. The current swathe of ecigarette marketing in the UK is chillingly reminiscent of the early days of tobacco advertising; this past experience suggests there is good reason to be deeply concerned.

Thailand has long been at the forefront of tobacco control in Southeast Asia. On 8 March 2013, it took another step forward when the health minister Dr Pradith Sinthawanarong signed a regulation requiring 85% pictorial (graphic) health warnings on cigarette packs. Current pictorial warnings are 55%.

The regulation is expected to take effect in approximately six months, and will mean Thailand has the largest graphic health warnings in the world. Currently, Australia has the largest total area at 82.5% (75% of front and 90% of back). Uruguay has the largest overall with 80% on the front and back. Sri Lanka is set to also implement 80% warnings, pending regulations. Within the Southeast Asia region Brunei, Singapore and Malaysia also have pictorial health warnings.

The move has been warmly welcomed by tobacco control advocates in the region. Southeast Asia Tobacco Control Alliance (SEATCA) Director Ms. Bungon Ritthiphakdee said: “SEATCA is ecstatic and would like to convey our heartiest congratulations to Thailand for its leadership in tobacco control. Its enactment of rules to put in place the largest GHWs on cigarette packs speaks to its political will and example to safeguard the health of its people.

With this development, however, SEATCA warned that the tobacco industry and related groups including tobacco farmers will likely lobby to fight and block the regulation. Just last month, the Thai Tobacco Trade Association submitted a letter to the Ministry of Health, Thailand, opposing the new health warning policy.

“When countries strengthen their policies, there is no doubt the tobacco industry will challenge the legislation especially measures that reduce tobacco consumption.  They have tried to delay Tobacco Control laws that are stringent, fight tobacco tax increases, and dilute bans on tobacco advertising sponsorship and promotions time and again,” Ms Ritthiphakdee adds.

SEATCA has recently launched a regional campaign to counter tactics of the tobacco industry to create fear and use tobacco farming to create opposition to the introduction of effective tobacco control measures. The campaign website (http://www.saveourfarmer.org) contains information about the economic contribution and costs of tobacco farming, health and environmental hazards, and contribution to government revenue.

The New Zealand government has announced it will introduce tobacco plain packaging. The announcement follows cabinet consideration of a public consultation process, held in late 2012, which received approximately 300 substantive submissions together with an additional 20,000 responses. The announcement puts New Zealand on track to become the second country in the world to introduce plain packaging. In order to manage potential legal risks, the government will wait to see the outcome of legal processes in Australia, with the intention of introducing legislation before the end of 2013. According to the government, tobacco is responsible for approximately 5000 deaths per year.

Read the full New Zealand government statement here.

Following Ruth Malone’s earlier letter declining to be part of a “facilitated dialogue” with the tobacco industry sponsored by the US Food and Drug Administration (FDA), the FDA revised the schedule and invited her again to a meeting with public health, academic and government tobacco control leaders on the first day and invited tobacco industry presentations on the second day. In the letter below, she explains why she is again declining to participate:

—-

Dear Dr. Deyton and tobacco control colleagues,

I do appreciate the attempts of the Center for Tobacco Products to respond to the issues raised in my previous letter declining the invitation to be part of the planned “dialogues” panel with the tobacco industry. But while I applaud the dropping of the “facilitated dialogues” meeting characterization, the proposed revised format (which clusters invited presentations from government, academics and public health representatives on day one, followed by invited presentations from the tobacco industry on day two) does not adequately address the substantive issues raised in my letter. It remains the same meeting, with the same agenda and purpose, merely rearranging the program. Therefore, I must again respectfully and regretfully decline your invitation to attend this particular meeting.

The first point raised in my previous letter related to regarding tobacco companies as equivalent “stakeholders” with public health. I see nothing in the revised format that changes this, since public health and tobacco company representatives continue to be placed on the same meeting agenda as coequals, albeit now on different days. Tobacco companies are stakeholders only in the promotion of tobacco product use, not promoting public health, which is the purpose of the Family Smoking Prevention and Tobacco Control Act. While the tobacco companies have every right to express their opinions and submit materials for the FDA’s consideration, you are not required to treat the regulated industry “equally” as though they had demonstrated materially that they share the goal of protecting public health. They have not done so.

My second point addressed the absence of mutual understanding of what constitutes legitimate science and ethical conduct in science. The revised format does nothing to reassure me that a reasonably comprehensive understanding of Judge Kessler’s extensive Findings of Fact in her ruling in the Department of Justice RICO case (USA v. Philip Morris et al.) is now informing the FDA’s activities or has been incorporated into the agenda. (These Findings of Fact are clearly relevant for the FDA to consider in its decision making, as indicated by the fact that Congress included three findings (numbers 47, 48, and 49) from Judge Kessler’s ruling in the Family Smoking Prevention and Tobacco Control Act.) While there has been a proliferation of smaller tobacco and nicotine device companies that are not defendants in the RICO case, the fact remains that the major cigarette companies continue to dominate the market both in this country and in the world, that they continue patterns of acquisition of the more promising smaller companies, and that the federal court found their fraudulent conduct was continuing and likely to continue into the future. This is highly material to any discussion of industry-sponsored tobacco products research.

Third, it is clear that this meeting has indeed had the effect of contributing to divisions within tobacco control, as some invitees now feel they must attend and others (including me) feel they must decline. Whether it is officially called “facilitated dialogue” or “public workshop” seems less important in this regard than the fact that it is still one and the same meeting with the chairs rearranged, and it did not have to happen this way. It is disturbing when public health agencies contribute to such divisions.

Fourth, the tobacco companies have every right to make comments and one would expect them to do so, and the FDA has a responsibility to give comments from the regulated industry fair consideration. But legal colleagues have advised me that while the FDA is certainly permitted to invite industry speakers to present at a meeting on how to deal with industry science, there is no legal requirement that they do so, and in the absence of such a requirement, I continue to question why FDA feels it must give the industry a stage. They certainly do not have such status even on the TPSAC, where they are separated by being non-voting members. Your legal mandate is to regulate this industry in the service of public health, not to provide it a podium for its propaganda.

The leading tobacco companies have repeatedly demonstrated antipathy to the FDA, creating multiple obstacles to its ability to carry out its responsibilities for implementing the Family Smoking Prevention and Tobacco Control Act. Far from being equal “stakeholders” in the FDA’s mission, some have sued to block implementation of health warning labels and others are openly flouting FDA’s regulations banning the use of “light” and “mild” and other descriptors, simply replacing these words with color coding. These are only the most obvious examples.

Our current moment does not call for a cautious, prolonged and exorbitantly expensive replay of the infamous “safer cigarette” debacles of the past, in which the tobacco industry “partnered” with health researchers in a cynical ploy to buy decades more time at the expense of millions of lives. What is called for now is the political courage to acknowledge and incorporate decisively in policy planning the vast evidence demonstrating that tobacco companies are untrustworthy—hence the need for strong, rapidly enacted and well-enforced regulations to protect the public from suffering another century of tobacco-caused deaths. What is called for now is informed, savvy leadership. I urge FDA to provide it.

Please enter this letter and the earlier letter to which it refers into the record of the meeting. If necessary, I would be willing to arrange for someone to attend and read these into the record.

Thank you for your consideration.

Ruth E. Malone, RN, PhD, FAAN
Professor and Chair, Department of Social & Behavioral Sciences
Editor-in-Chief, Tobacco Control

Download PDF of Letter to FDA

Kelley Lee

London School of Hygiene & Tropical Medicine

In an email invitation to its “Health is Global, Partners Forum”, held on 22 November 2012, the UK Department of Health expressed pleasure that The Right Honourable Kenneth Clarke QC MP (Minister without portfolio and Trade Envoy) would speak on Trade for Better Health. The one-day meeting is an annual event bringing together key partners concerned with the UK’s Health is Global Strategy.

The DOH’s Global Health Team, however, could not have picked a more controversial British politician to headline its annual partners’ meeting. Clarke has been a Member of Parliament since 1970, serving as minister under the Thatcher, Major and now Cameron governments. His popularity has, in large part, been due to his personae as a somewhat jovial uncle. The controversy that has dogged his career, some argue preventing him from becoming Prime Minister, has been his close relationship with the tobacco industry.

After leaving office in 1998, Clarke became a director and deputy chairman of British American Tobacco (BAT), a position he occupied until 2007. The release of internal company documents led to allegations that he accepted hospitality from BAT while Chancellor of the Exchequer, in one case, thanking then BAT Chairman Patrick Sheehy for a “note and folder”, and promising to discuss it with the Treasury.

After joining the company, he played a leading role in expanding access to overseas markets such as Vietnam. When allegations broke of the company’s complicity in cigarette smuggling, Clarke defended BAT to the House of Commons Health Select Committee as “a company of integrity” and “an extremely good corporate citizen”. Evidence of smuggling has continued to accumulate including on Vietnam.

Upon returning to office as Justice Minister in 2010, and allegedly under pressure from business lobby groups, Clarke was accused of trying to delay and limit the jurisdiction of the Serious Fraud Office under the Bribery Act 2010.

All of this would suggest that Clarke is no friend to any strategy to promote “global health”. Yet the evident delight of the Global Health Team in inviting Clarke may reflect a shift in how the DOH is interpreting its mandate under this strategy. Launched with much fanfare by then Prime Minister Gordon Brown in 2008, development lay at the heart of the Labour government’s global health strategy. As described in The Lancet, “better health in poor countries is good for our own health, as well as being essential to improving wellbeing and tackling poverty globally.”

Under the present Coalition government, and during a period of economic austerity, global health has cosied up to trade policy.  Global health is a market opportunity, in other words, for UK plc to earn a few pounds.

This latest incarnation of Clarke, as a global health partner, is perhaps unsurprising. After all, Clarke is no stranger to irony. As health secretary from 1988-90 he remained infamous for his cigar smoking and less than healthy lifestyle. He was chancellor, responsible for ensuring that Customs and Excise were not cheated of its revenue, throughout the period when BAT is accused of smuggling billions of cigarettes worldwide. He was the company director who brokered the BAT-sponsored creation of the International Centre for Corporate Social Responsibility at Nottingham University. However, this didn’t stop the company maintaining operations in Burma and Uzbekistan.

He is now minister without a portfolio which, it would seem, gives him a free hand to have a jovial laugh at the expense of the DoH’s global health strategy.