At an investor day held in late September 2016, PMI chief executive officer Andre Calantzopolous outlined the company’s strategic priorities, which include “to continue leading the combustible product category and deliver against our current growth algorithm” and for “Reduced risk products (RRPs) to ultimately replace cigarettes to the benefit of all stakeholders”. Calantzopoulos described the ‘excellent combustible fundamentals’ which include: improving cigarette industry volume/trend mix, and broad and balanced geographic footprint with expansion opportunities. While these are not exactly the words of a leader who wants to get out of the cigarette business, he also states that the company is committed to achieving widespread conversion to RRPs, and that PMI “welcome all alternatives to achieve a combustion-free world as quickly as possible.” Together these contradictory priorities sound very much like a bet each way.
At first glance, the latter rhetoric sounds like the company has finally – after more than 50 years of denial and deceit about the harms of tobacco – realised that not only is the tobacco business ethically and morally bankrupt, but it is also the wrong profit-making horse to back. However, a closer look suggests that reduced risk products may be yet another cynical tactic for the company to position itself as a socially responsible entity that deserves to be treated as part of the solution, rather than the problem.
The glaring omission in the rhetoric is the most obvious alternative for PMI to meaningfully contribute to achieving a combustion-free world: announce a date by which the company will phase out combustible products entirely. Calantzopoulos is on record as stating the iQOS (I Quit Ordinary Smoking) technology which appears to be the platform it is pinning most hope on, put the industry “on the cusp of a revolution”. At the September meeting, he told investors that almost one million smokers have already converted to RRPs and it had captured nearly 3% of the Japanese cigarette market. Wells Fargo Securities tobacco analyst Bonnie Herzog estimates that iQOS could displace 30% of the global combustible market by 2025.
At the September 2016 investor day, Calantzopoulos was not shy about framing RRPs as a public health solution with enormous potential, claiming “…if we can encourage a meaningful portion of adult smokers to rapidly switch to RRPs that meet this standard, it is likely to create a significant additional population health benefit relative to current regulatory efforts.” He called on the public health community to embrace this approach, and noted “we are very much encouraged by the growing number of pre-eminent public health advocates that already support the principle of tobacco harm reduction through products and science.”
The public health community has seen similar promises before: the promise of reduced risk products is nothing new, and the safety of iQOS is largely untested. If these products fail, as their predecessors have done, PMI will have benefited from iQOS and other reduced risk products being branded consistently with its combustible tobacco products.
Presumably anticipating such objections, Calantzopoulos noted, “I fully recognise there is scepticism and a deficit of trust in our determination to lead the effort to achieve a combustion-free world as soon as possible. Although we cannot change the past, we can certainly change the future and transform our company.”
Indeed, PMI can certainly change the future and transform the company. Nothing will accelerate the transition to a smoke free world more effectively than PMI withdrawing completely from the combustibles market, supported by the intensive consumer engagement strategies it is already using to promote uptake of iQOS.
Public health advocates who are willing to work with the tobacco industry on joint harm reduction approaches would do well to remember the fable of the scorpion and the frog, in which the frog agrees to carry the scorpion across a stream. Halfway across, the scorpion stings the frog. As they both start to drown, the frog asks ‘why?’, to which the scorpion replies ‘it’s my nature’.
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.
On 8 September, New Zealand joined a growing international move to outlaw the tobacco industry’s ‘silent salesman’ when it became the latest country to introduce cigarette plain packaging.
The legislation – the Smoke-Free Environments (Tobacco Standardised Packaging) Amendment Bill was passed on its third and final reading in the New Zealand parliament with 108 votes in favour, 13 against.
The move has been welcomed by health experts as a an important measure towards achieving the goal of Smokefree 2025. Professor Janet Hoek, co-director of research group Aspire 2025 said: “Standardised packaging is a pivotal measure in the road to Smokefree 2025. It transforms tobacco packaging from a highly effective marketing tool, particularly for youth and young adults, to a plain and unattractive object. For decades, tobacco companies have used skilfully designed packaging to help attract the next generation of smokers and the government has rightly ended this practice.”
Professor Hoek has led several studies on cigarette plain packaging, as well as an innovative study on the potential for dissuasive cigarette sticks.
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
Across forty years I’ve come to recognise many factoid-driven myths about smoking that just won’t die. If I asked for a dollar each time I had to refute these statements, I’d have accumulated a small fortune.
Their persistence owes much to their being a vehicle for those who utter them to express unvoiced but clear sub-texts that reflect deeply held beliefs about women, the disadvantaged, mental illness, government health campaigns and the “natural”.
Let’s drive a stake through the heart of ten of the most common myths.
1. Women and girls smoke more than men and boys
Women have never smoked more than men. Occasionally, a survey will show one age band where it’s the other way around, but from the earliest mass uptake of smoking in the first decades of last century, men streaked out way ahead of women.
In 1945 in Australia, 72% of men and 26% of women smoked. By 1976, men had fallen to 43% and women had risen to 33%.
As a result, men’s tobacco-caused death rates have always been much higher than those of women. Women’s lung cancer rates, for example, seem unlikely to reach even half the peak rates that we saw among men in the 1970s.
But what about all the “young girls” you can see smoking, I’m always being told. In 2014, 13% of 17-year-old male high school students and 11% of females smoked. In two younger age bands, girls smoked more (by a single percentage point).
Those who keep on insisting girls smoke more are probably just letting their sexist outrage show about noticing girls’ smoking than their ignorance about the data.
2. Quit campaigns don’t work on low socioeconomic smokers
In Australia, 11% of those in the highest quintile of economic advantage smoke, compared with 27.6% in the lowest quintile. More than double.
So does this mean that our quit campaigns “don’t work” on the least well-off?
Smoking prevalence data reflect two things: the proportion of people who ever smoked, and the proportion who quit.
If we look at the most disadvantaged group, we find that a far higher proportion take up smoking than in their more well-to-do counterparts. Only 39.5% have never smoked compared with 50.4% of the most advantaged – see table 9.2.6).
When it comes to quitting, 46% of the most disadvantaged have quit compared to 66% of the least disadvantaged (see table 9.2.9).
There is a higher percentage of the disadvantaged who smoke mainly because more take it up, not because disadvantaged smokers can’t or won’t quit. With 27.6% of the most disadvantaged smoking today, the good news is that nearly three-quarters don’t. Smoking and disadvantage are hardly inseparable.
3. Scare campaigns ‘don’t work’
Countless studies have asked ex-smokers why they stopped and current smokers about why they are trying to stop. I have never seen such a study when there was not daylight between the first reason cited (worry about health consequences) and the second most nominated reason (usually cost).
For example, this national US study covering 13 years showed “concern for your own current or future health” was nominated by 91.6% of ex-smokers as the main reason they quit, compared with 58.7% naming expense and 55.7% being concerned about the impact of their smoking on others.
If information and warnings about the dire consequences of smoking “don’t work”, then from where do all these ex-smokers ever get these top-of-mind concerns? They don’t pop into their heads by magic. They encounter them via anti-smoking campaigns, pack warnings, news stories about research and personal experiences with dying family and friends. The scare campaigns work.
4. Roll-your-own tobacco is more ‘natural’ than factory made
People who smoke rollies often look you in the eye and tell you that factory made cigarettes are full of chemical additives, while roll-your-own tobacco is “natural” – it’s just tobacco. The reasoning here that we are supposed to understand is that it’s these chemicals that are the problem, while the tobacco, being “natural”, is somehow OK.
This myth was first turned very unceremoniously on its head when New Zealand authorities ordered the tobacco companies to provide them with data on the total weight of additives in factory made cigarettes, roll-your-own and pipe tobacco.
For example, data from 1991 supplied by WD & HO Wills showed that in 879,219kg of cigarettes, there was 1,803kg of additives (0.2%). While in 366,036kg of roll-your-own tobacco, there was 82,456kg of additives (22.5%)!
Roll-your-own tobacco is pickled in flavouring and humectant chemicals, the latter being used to keep the tobacco from drying out when smokers expose the tobacco to the air 20 or more times a day when they remove tobacco to roll up a cigarette.
5. Nearly all people with schizophrenia smoke
It’s true that people with mental health problems are much more likely to smoke than those without diagnosed mental health conditions. A meta-analysis of 42 studies on tobacco smoking by those with schizophrenia found an average 62% smoking prevalence (range 14%-88%). But guess which study in these 42 gets cited and quoted far more than any of the others?
If you said the one reporting 88% smoking prevalence you’d be correct. This small 1986 US study of just 277 outpatients with schizophrenia has today been cited a remarkable 1,135 times. With colleagues, I investigated this flagrant example of citation bias (where startling but atypical results stand out in literature searches and get high citations – “wow! This one’s got a high number, let’s quote that one!”).
By googling “How many schizophrenics smoke”, we showed how this percolates into the community via media reports where figures are rounded up in statements such as, “As many as 90% of schizophrenic patients smoke.”
Endlessly repeating that “90%” of those with schizophrenia smoke does these people a real disservice. We would not tolerate such inaccuracy about any other group.
6. Everyone knows the risks of smoking
Knowledge about the risks of smoking can exist at four levels:
Level 1: having heard that smoking increases health risks.
Level 2: being aware that specific diseases are caused by smoking.
Level 3: accurately appreciating the meaning, severity, and probabilities of developing tobacco related diseases.
Level 4: personally accepting that the risks inherent in levels 1–3 apply to one’s own risk of contracting such diseases.
Level 1 knowledge is very high, but as you move up the levels, knowledge and understanding greatly diminish. Very few people, for example, are likely to know that two in three long term smokers will die of a smoking caused disease, nor the average number of years that smokers lose off normal life expectancy.
7. You can reduce the health risks of smoking by just cutting down
It’s true that if you smoke five cigarettes a day rather than 20, your lifetime risk of early death is less (although check the risks for one to four cigarettes a day here).
But trying to “reverse engineer” the risk by just cutting down rather than quitting has been shown in at least four large cohort studies such as this one to confer no harm reduction.
If you want to reduce risk, quitting altogether should be your goal.
8. Air pollution is the real cause of lung cancer
Air pollution is unequivocally a major health risk. By “pollution”, those who make this argument don’t mean natural particulate matter such as pollen and soil dusts, they mean nasty industrial and vehicle pollution.
The most polluted areas of Australia are cities where pollution from industry and motor vehicle emissions are most concentrated. Remote regions of the country are the least polluted, so if we wanted to consider the relative contributions of air pollution and smoking to smoking-caused diseases, an obvious question to ask would be “does the incidence of lung cancer differ between heavily polluted cities and very unpolluted remote areas?”
Yes it does. Lung cancer incidence is highest in Australia in (wait for this …) in the least polluted very remote regions of the country, where smoking prevalence happens also to be highest.
9. Smokers should not try to quit without professional help or drugs
If you ask 100 ex-smokers how they quit, between two-thirds and three-quarters will tell you they quit unaided: on their final successful quit attempt, they did not use nicotine replacement therapy, prescribed drugs, or go to some dedicated smoking cessation clinic or experience the laying on of hands from some alternative medicine therapist. They quit unaided.
So if you ask the question: “What method is used by most successful quitters when they quit?” The answer is cold turkey.
Fine print on this English National Health Service poster states a bald-faced lie by saying that “There are some people who can go cold turkey and stop. But there aren’t many of them.” In the years before nicotine-replacement threapy and other drugs were available, many millions – including heavy smokers – quit smoking without any assistance. That’s a message that the pharmaceutical industry was rather not megaphoned.
Not true. NHS poster.
10. Many smokers live into very old age: so it can’t be that harmful
In just the way that five out of six participants in a round of deadly Russian roulette might proclaim that putting a loaded gun to their head and pulling the trigger caused no harm, those who use this argument are just ignorant of risks and probability.
Many probably buy lottery tickets with the same deep knowing that they have a good chance of winning.
Ten more myths about smoking that will not die
There’s plainly a big appetite for smoking myth busting, so here are 10 more.
1. Today’s smokers are all hard core, addicted smokers who can’t or won’t give up
This claim is the essence of what is known as the “hardening hypothesis”: the idea that decades of effort to motivate smokers to quit has seen all the low-hanging fruit fall from the tree, leaving only deeply addicted, heavy smokers today.
The key index of addicted smoking is the number of cigarettes smoked per day. This creates a small problem for the hardening hypothesis: in nations and states where smoking has reduced most, the average number of cigarettes smoked daily by continuing smokers has gone down, not up. This is exactly the opposite of what the hardening hypothesis would predict if remaining smokers were mostly hard core.
2. Smoking is pleasurable
Repeated studies have found that around 90% of smokers regret having started, and some 40% make an attempt to quit each year. There’s no other product with even a fraction of such customer disloyalty.
But I’m always amused at some die-hard smokers’ efforts explain that they smoke for pleasure and so efforts to persuade them to stop are essentially just anti-hedonistic tirades. Many studies have documented that the “pleasure” of smoking centres around the relief smokers get when they have not smoked for a while. The next nicotine hit takes away the discomfort and craving they have been experiencing.
This argument is a bit like saying that being beaten up every day is something you want to continue with, because hey, it feels so good when the beating stops for a while.
3. Light and mild cigarettes deliver far less tar and nicotine to the smoker than standard varieties
Several nations have outlawed cigarette descriptors such as “light” and “mild” because of evidence that such products do not deliver lower amounts of tar and nicotine to smokers, and so are deceptive.
The allegedly lower yields from cigarettes labelled this way resulted from a massive consumer fraud.
Cigarette manufacturers obtained these low readings by laboratory smoking machine protocols which took a standardized number of puffs, at a standardized puff velocity. The smoke inhaled by the machine was then collected in glass “lungs” behind the machine and the tar and nicotine weighed to give the readings per cigarette.
But the companies didn’t tell smokers two things. So-called light or mild cigarettes had tiny, near-invisible pin-prick perforations just on the filter (see picture). These holes are not covered by the “lips” or “fingers” of the laboratory smoking machine, allowing extra air to be inhaled and thus diluting the dose of tar and nicotine being collected.
But when smokers use these products, two things happen. Their lips and fingers partially occlude the tiny ventilation holes, thus allowing more smoke to be inhaled. Smokers unconsciously “titrate” their smoking to obtain the dose of nicotine that their brain’s addiction centres demand: they can take more puffs, inhale more deeply, leave shorter butt lengths or smoke more cigarettes.
Today, where use of these descriptors has been stopped, the consumer deception continues with the companies using pack colours to loudly hint to smokers about which varieties are “safer”.
Magnification and location of filter ventilation holes. Author collection
4. Filters on cigarettes remove most of the nasty stuff from cigarettes
We’ve all seen the brown stain in a discarded cigarette butt. But what few have seen is how much of that same muck enters the lungs and how much stays there.
This utterly compelling video demonstration shows how ineffective filters are in removing this deadly sludge. A smoker demonstrates holding the smoke in his mouth and then exhales it through a tissue paper, leaving a tell-tale brown stain. He then inhales a drag deep into his lungs, and exhales it into a tissue. The residue is still there, but in a much reduced amount. So where has the remainder gone? It’s still in the lungs!
5. Governments don’t want smoking to fall because they are addicted to tobacco tax and don’t want to kill a goose that lays golden eggs
This is perhaps the silliest and most fiscally illiterate argument we hear about smoking. If governments really want to maximise smoking and tax receipts, they are doing a shockingly bad job of it. Smoking in Australia has fallen almost continuously since the early 1960s. In five of the 11 years to 2011, the Australian government received less tobacco tax receipts than it did the year before (see Table 13.6.6).
Plainly, as smoking continues to decline, diminishing tax returns will occur, although this will be cushioned by the rising population which will include some smokers.
In the meantime, tobacco tax is a win-win for governments and the community. It reduces smoking like nothing else, and it provides substantial transfer of funds from smokers to government for public expenditure.
Those of us who don’t smoke do not squirrel away what we would have otherwise spent on smoking in a jam jar under the bed. We spend it on other goods and services, benefiting the economy too.
6. Most smokers die from smoking caused diseases late in life, and we’ve all got to die from something
Smoking increases the risk of many different diseases, and collectively these take about ten years off normal life expectancy from those who get them.
Smoking is by far the greatest risk factor for lung cancer. In Australia, the average age of death for people with lung cancer is 71.4 (see Table 4.2), while life expectancy is currently 80.1 for men and 84.3 for women.
This means that, on average, men diagnosed with lung cancer lose 8.7 years and women 12.9 years (mean 10.8 years). Of course, some lose many more (Beatle George Harrison died at just 58, Nat King Cole at 45).
If a 20-a-day smoker starts at 17 and dies at 71, 54 years of smoking would see 394,470 cigarettes smoked. At ten puffs per cigarette, that’s some 3.94 million point-blank lung bastings.
It takes about six minutes to smoke a cigarette. So at 20 a day, smokers smoke for two hours each day. Across 54 years, that’s a cumulative 1,644 days of smoking (4.5 years of continual smoking if you put it all together).
So by losing ten years off life expectancy, each cigarette smoked takes about 2.2 times the time it takes to smoke it off the life expectancy that might otherwise have been enjoyed.
7. Smokers cost the health system far more than the government receives from tobacco tax
In June 2015, a senior staff member of Australian libertarian Senator David Leyonhjelm, Helen Dale tweeted:
In Australia, a now old report looking at 2004/05 data estimated the gross health care costs attributable to smoking “before adjustment for savings due to premature death” were $A1.836 billion. In that financial year, the government received $A7,816.35 billion in customs and excise duty and GST on tobacco.
Someone who thought that the fiscal ledger was all that mattered in good government might conclude from this that smokers easily pay their way and perhaps we should even encourage smoking as a citizen’s patriotic duty.
With smokers being considerate enough to die early, these noble citizens lay down their lives early and thus contribute “savings due to premature death” like failing to draw a state pension or needing aged care services late in life. Philip Morris notoriously gave this advice to the new Czech government in 1999.
Other assessments, though, might well point to the values inherent in such assessments. History’s worst regimes have often seen economically non-productive people as human detritus deserving death. Primo Levi’s unforgettable witnessing of this mentality in Auschwitz comes to mind.
8. Big Tobacco is starting to invade low-income nations, now that smoking is on the wane in the wealthiest nations
Sorry, but US and British manufacturers have been aggressively marketing cigarettes in places such as China since the early years of last century. These collectable posters show many featuring Chinese women.
The large populations, the often lax tobacco-control policies and the higher corruption indexes of many low- and middle-income nations makes many of these nirvanas for Big Tobacco.
There are fewer more nauseating experiences than reading the corporate social responsibility reports of tobacco transnationals and then seeing how they operate in smokers’ paradises such as Indonesia. This documentary says it all.
9. Millions of cigarette butts on the world’s beaches leach lots of toxic chemicals into oceans
Cigarette butts are the most discarded items in all litter. Every year uncounted millions if not billions are washed down gutters in storm water and find their way into rivers, harbours and oceans. Cigarette filters and butts contain toxic residue and experiments have shown that placing laboratory fish in containers for 48 hours with leachate extracted from used cigarette butts, 50% of the fish die. From this, we sometimes hear people exclaim that cigarette butts are not just unsightly, but they “poison the oceans”.
But a confined laboratory container does not remotely mirror real life exposures in oceans or rivers. There are some 1,338,000,000 cubic kilometers of water in the world oceans, so the contribution of cigarette butts to the toxification of all this could only excite a homeopath.
If we want to reduce tobacco litter, we need not wander into such dubious justifications. The best way by far is to keep reducing smoking. Industry attempts at portraying themselves as corporately responsible by running dinky little clean-up campaigns or distributing personal butt disposal canisters avoids their efforts to keep as many smoking as possible.
10. Tobacco companies care deeply about their best customers dying early
Naturally, all businesses would rather their customers lived as long as possible so that the cash registers can keep ringing out long and loud. Tobacco companies wish their products didn’t kill so many, but worship the god nicotine for its iron grip on so many.
Visit any tobacco transnational’s website and you will find lots of earnest and caring talk about the companies’ dedication to doing all they can to reduce the terrible harm caused by their products. All the major companies have now invested heavily in electronic cigarettes, so isn’t this a sign that they taking harm reduction seriously?
It might be if the same companies were showing any sign of taking their feet off the turbo-drive accelerator of opposing effective tobacco control policies. But they are doing nothing of the sort. All continue to aggressively attack and delay any policy like tax hikes, graphic health warnings, plain packaging and advertising bans wherever in the world these are planned for introduction.
For all their unctuous hand-wringing about their mission to reduce harm, they are all utterly determined to keep as many smoking as possible. Big Tobacco’s business plan is not smoking or ecigarettes. It’s smoking and ecigarettes. Smoke when you are able to, vape when you can’t. It’s called dual use and some 70% of vapers are doing just that. The tragedy now playing out in some nations is that too many gormless tobacco control experts are blind to this big picture.
In a 2014 open letter to the WHO’s director general Margaret Chan signed by 53 researchers, it was argued “Controls on [ecigarette] advertising to nonsmokers, and particularly to young people are certainly justified, but a total ban would have many negative effects, including protection of the cigarette market and implicit support for tobacco companies. It is possible to target advertising at existing smokers where the benefits are potentially huge and the risks minimal.”
Clive Bates who “had a hand” in organising the letter but curiously did not sign it, is a former director of England’s Action on Smoking and Health. In that role, Bates directed and wrote one of the most excoriating critiques ever published of the tobacco industry’s long standing (and still running) denials of its designs on children.
In the October 2000 Danger in the Playground, Bates documented many of the most telling examples of candid industry talk about the vital role of children to the future of tobacco industry profitability. This accompanying powerpoint presentation (also authored by Bates) rubs it in even harder. These revelations were all made in internal tobacco industry documents released through the US Master Settlement Agreement between US state governments the tobacco industry, millions of which are now freely available here.
The tobacco industry’s business model about the importance of youth smoking was never put more succinctly than in this 1984 document from an RJ Reynolds tobacco official: “If younger adults turn away from smoking, the industry will decline, just as a population which does not give birth will eventually dwindle.” (“younger adults” was industry code from the mid 1970s for children and young adults, to be used in all written communications)
In a 2000 press statement at the time of the launch of the publication, Bates said “When you look at what they say privately, and compare it to their public posturing, the whole idea that tobacco companies might be working against teenage smoking is revealed as sinister self-serving public relations. The more they try to define smoking as only for adults, the more they are saying ‘hey kids, smoking’s for grown-ups’ with a sly nod and a cynical wink.”
Today, Bates runs his own consultancy business and is a leading advocate of ecigarettes. Of 220 tweets he posted between Oct 1 and Nov 1, 80% were about ecigarettes. On a recent blog he wrote that when it comes to ecigarettes “There is little evidence of marketing to children, only assertions that certain ads or brands are designed to appeal to children but with no empirical evidence, and apparently minimal understanding of modern advertising.”
On reading this, I was struck by how far Bates appears to have moved in the 15 years since he wrote Danger in the Playground and so tweeted a juxtaposition of the two quotes above, asking “which Clive Bates to believe?”
Bates replied challenging this apparent inconsistency, arguing that his 2000 statement referred to tobacco companies while his 2015 statement referred to ecigarette companies. He argued that currently, the vaping market is worth 100 times less than the cigarette market and that “nearly all vape customers come from the ranks of existing smokers”, which he said explains why adult smokers are the target market for ecigs.
The same analysis can of course be applied to the current contribution of young smokers to the total cigarette market. For example, an early Australian analysis showed that while in one year the value of the underage market to manufacturers was $AUD18.7million, if 50% of young smokers continued to smoke, they would contribute $AUD112 billion at current prices to the industry across their lifetime.
Bates knows perfectly that tobacco companies understand the importance of smoking uptake by children to their future, but seems to believe that such a thought has never crossed the minds of ecig manufacturers.
In an extraordinary statement, he wrote that “there are good reasons why the e-cigarette companies, even tobacco owned ones, would not target adolescents … demand, reputational, legal and regulatory risk etc … it would be bad business.”
This language only needs to be contrasted with the many counterfactual examples he supplied in his own 2000 publication. Yes, there are many good reasons why designs on kids need to be publicly denied. As one 1973 tobacco document describing a supposed anti-youth smoking initiative put it “This is one of the proposals that we shall initiate to show that we as an industry are doing something about discouraging young people to smoke. This of course is a phony way of showing sincerity as we all well know.”
In much the same way as the tobacco industry has long done, many of those promoting vaping are today trying to walk on both sides of the street on youth vaping. They know the reputational risk of openly saying that they are unconcerned about youth uptake. Whenever data show negligible uptake by youth, this is rapidly megaphoned as self-evidently a good thing. But when data show significant use, they try to spin this as being an entirely positive development where it happens: all children who are now vaping would have been smoking instead, these clairvoyants assure us.
In the USA today data from the US National Youth Tobacco Survey show that while cigarette smoking continues to fall in US teenagers, e-cigarette use has been dramatically increasing since 2011 and is now way ahead of cigarette smoking: there are now some 50% more middle and high school kids vaping than are smoking, with an estimated 340,000 vaping on more than 20 days each month. Advertising like this, and 3 year old birthday party favourite flavours like these which Bates thinks should be allowed, are plainly intended to beguile teenagers.
A recent systematic review in the Lancet of nicotine and psychosis concluded that “Daily tobacco use is associated with increased risk of psychosis and an earlier age at onset of psychotic illness. The possibility of a causal link between tobacco use and psychosis merits further examination.” It set out important arguments about why the “self-medication” hypothesis about nicotine (promoted by the tobacco industry) deserves reassessment against one where nicotine might be causative in psychosis. Such serious considerations demand that trite dismissals of nicotine as being as benign as “like drinking coffee or something” be condemned.
Clive Bates and others who signed his letter might like to comment on how “it is possible to target [ecigarette] advertising at existing smokers”; how many of these allegedly “adult targeted” ads would never attract the interest of non-smoking teens; and where parents can buy one of the miraculous magic filters that let such advertising through to smokers but somehow render it invisible or uninteresting to young non-smokers.
Kerala has become the first state in India to become tobacco advertisement free. This major milestone for public health in the country represents strong government commitment, a favourable policy framework, accountability, and engagement by various departments to achieve robust enforcement.
The first step was successfully abolishing tobacco advertisements at the points-of-sale – an effective and easy option used to create a sustained reminder about these dangerously addictive products. According to the Global Adult Tobacco Survey 2009-10, 44.2%, 70.9% and 72.3% of Kerala adults above 15 had seen advertisements on cigarettes, bidis and smokeless tobacco respectively.
Kerala is home to 34 million people. The state’s Chief Minister Mr Oommen Chandy has said, “Public health has been and will be our priority. Over the last four years, we have undertaken far-reaching tobacco demand and supply reduction measures such as a ban on pan masala and gutkha containing tobacco or nicotine, an increase in tobacco product taxes, and successful completion of the drive to remove advertisements at the points-of-sale in the state.”
The Public Health wing of the Kerala Health Services Department spearheaded the extensive campaign that resulted in removal of tobacco advertisements from 95.3% of points-of-sale over an 18-month period across 14 districts of the state. Kerala Police joined forces in this mega effort.
Dr AS Pradeep Kumar, a medical doctor with a PhD in tobacco control and then Additional Director of Health Services (Public Health) who coordinated this effort, said a three-phase activity plan was developed with District Medical Officers at the core. “Sensitisation programmes were conducted with emphasis on Section 5 of COTPA for district officers at the state capital. (COTPA is India’s tobacco control law; Section 5 bans all forms of direct or indirect tobacco product advertising). District officers in turn trained and authorised personnel attached to Primary Health Centres” he added.
The districts were given the freedom to customise according to their local needs. “This, in turn, raised the level of commitments and ownership taking. At the state level, we supported the districts by framing guidelines, monitoring and advising course corrections,” said Dr Kumar.
The process that started during World No Tobacco Day 2013 saw both integrated and intense drives that effectively pooled the services of health personnel from district to primary health centre level. Over 1,30,000 points-of-sale were inspected in drives held in two phases, from June to December 2013, and in January 2014, and notices issued to erring outlets. Notices mandated that advertisement boards, stickers, or posters be removed within 7-10 days. Wherever ads were not removed, they were confiscated. Police assisted as needed. Regular monitoring continued until October 2014.
An evaluation study by an external agency reported an overall compliance of 95.3% – 98.5% of points-of-sale free of any advertisement hoardings and 96.7% of points-of-sale free from stickers and print advertisements. The evaluation team, with 90 trained volunteers,m observed 22,344 points-of-sale across the state. Kerala Voluntary Health Services, a civil society organisation with nearly four-decade-long experience in research and field implementation in Kerala conducted the evaluation study. The team looked out for hoardings, posters, stickers, display of cost, display of tobacco products or any other promotional material at points-of-sale.
In November 2014, Kerala was declared the first tobacco ad-free state in India. Sustainability of the achievement is being ensured by integrating it with ongoing inspections by the Health Department in the state.
The American Red Cross is under increasing pressure to refuse tobacco industry donations, to bring it into line with guidelines of the International Federation of Red Cross and Red Crescent Societies and most of the 189 national affiliates. Accepting tobacco funding is in clear breach of the first of the seven Fundamental Principles of the International Red Cross and Red Crescent Movement – Humanity, which includes the statement: “[the Movement’s] purpose is to protect life and health and to ensure respect for the human being”.
The principles and rules for Red Cross and Red Crescent Humanitarian Assistance (principles 7.5 and 7.6) state in regard to relations with the external actors: “National Societies and the International Federation shall enter into partnerships with private sector actors that…have a positive image, and a track record of good ethical behaviour” and “…shall not accept donations from sources which risk the image or reputation of any component of the Movement”. On both counts, the association with Altria Group fails.
The value of partnering with the Red Cross is clearly outlined on the International Red Cross website, which includes among the benefits to corporations: demonstration of corporate social responsibility and “that consumers – both current and potential – have a more positive image of a company that supports a cause they care about.” The American Red Cross website recognises Altria Group on the webpage of its Annual Disaster Giving Program (ADGP), which notes that “…ADGP members are valued Red Cross donors. They receive a high level of recognition and access to Red Cross information and leadership.” About Altria Group, it says: “Altria and its companies…have a long-standing relationship with the American Red Cross; we share a tradition of providing support to people and communities in times of need”. The millions who have lost family members to smoking, hooked by Marlboro’s seductive advertising while they were kids, may disagree.
A spokeswoman for the American Red Cross Laura Howe, was quoted in a Reuters report of the issue that the organisation was “happy to accept any funds that support its efforts to assist disaster victims.” The double standards implicit in the statement is striking, given the annual death toll from tobacco products in the USA is over 400,000 – far in excess of any other natural or human-caused disaster. By way of comparison, Altria Group donated US$1 million to assist with Hurricane Sandy relief efforts, for which the US death toll was 117.
While the American Red Cross won’t engage in cause marketing or imply an endorsement of a tobacco product, the value of the association to Altria Group is as clear as would be the case if the Red Cross allowed its logo to be merged with the Marlboro logo.
Depending on the type of national regulation, cigarette vending machines pose serious problems for tobacco control including: increasing cigarette availability, facilitating smoking relapse, providing cigarette access points for children and other non-smokers, normalizing cigarette purchases , and serving as a promotional tool for the tobacco industry.
There is a wide range of variations concerning how different nations regulate cigarette vending machines. Some countries like England, Greece, Croatia and Singapore have outright bans, while many others restrict machines to over 18 venues and/or mandate staff to verify age, sometimes issuing special tokens or requiring staff to operate machines.
In July, 2014, while holidaying in Stuttgart, I was shocked to see how ubiquitous cigarette machines were in public places. Amongst developed countries, Germany must rank as one of the nations with the most laissez-faire approach to cigarette vending machine control. In a suburban street outside my Stuttgart hotel, one vending machine was located right next to a small park where children of all ages were observed playing ball games. This site was also only approximately 20 metres from a busy pre-school. What a marvelous way for the tobacco industry to show the pre-schoolers on a daily basis just how socially acceptable smoking is.
To operate vending machines, a German identity card or driver’s licence is required to ‘prove’ the purchaser was over 18. How easy would it be, however, for a child to borrow, with or without permission, an adult’s age verification, or for parents to send their child to buy cigarettes for them? Interestingly, the machine near the hotel required a minimum purchase of two cigarette packs: excellent for cementing relapses or for fostering dependence in experimental smokers.
Vending machine affixed to low wall on footpath next to small park frequented by children of all ages.
Another machine was photographed on the external wall of a shop in a village square about 30 minutes from Stuttgart, opposite the small town hall. Although there were some small advertisements for other goods on the few shops in the square, the cigarette picture on the vending machine was both the most eye-catching and the largest promotional item in the area.
Vending machine with large cigarette ‘ advertisement’ mounted on the external wall of a shop facing the village square and town hall.
It seems extraordinary that the placement of vending machines in public streets probably makes cigarettes the most accessible retail product in Germany. Germans certainly have a long way to go when it comes to eliminating the harmful influence of cigarette vending machines on public health.
The ubiquitous Myanmar tea house. You can hear the buzz of Burmese conversation emanating from such meeting places day and night. Old people on their daily catch up with neighbours meet here. Young people hang out and compare their new mobile phones here. New mums show off their beautiful babies here. We love these plentiful and congenial meeting places and can’t wait to find a table every morning as “coffee-o’clock” comes round. They call them tea houses and yes, the green tea comes complementary – but you pay for the coffee, and what coffee it is!
For foreigners like us it’s quite a display. With a broad smile and a flourish we see the young Burmese attendant hold a can high in the air and squirt condensed milk into a tin mug before adding a hot coffee mixture and depositing the combined steaming sweet stuff into tiny white cups. We have had to leave our usual coffee tastes behind, reminding ourselves that this is not our favourite Italian cafe back home in Sydney. No tattooed baristas proudly producing perfect espressos here. Myanmar coffee might not be to our taste, but it’s how the locals like it. So we’ve just had to get used to it.
But there is something happening in Myanmar’s tea houses that we will not get used to, nor accept: the massive increase in young people smoking, and the way in which the happy atmosphere and simple daily pleasantries of this much-loved tea house tradition have been besmirched by cigarettes and tobacco promotion.
Over the last four years my partner and I have been visiting Myanmar, we have seen one of the poorest countries in the world begin a magnificent transformation. When we first came, villagers we talked to would not speak Aung San Suu Kyi’s name for fear they would be taken away. Internet and mobile phones were restricted, new cars were as rare as hens’ teeth. But no more: the Myanmar that was a closed oppressive place four years ago with less than 300,000 visitors a year, will in 2014 welcome more than one million people. It is opening up to, and being accepted by, the world.
Must these people, now on the brink of political liberation after waiting for 60 years, be conned by the great marketers, big tobacco, into a life of increased disease and premature death?
In the tea house we see all the tricks and methods we witnessed in our youth in Australia. On each table next to the chilli sauce and serviette dispenser is a small clear plastic container containing loose cigarettes. Yesterday there was a promotion, so these cigarettes were free. Today the same cigarettes are five cents each. Pavlovian behaviour predicts that each day more and more young people will experiment. As we watch we see this happening; finding five cents to purchase a single cigarette is easy. The young boys who deliver our coffees with laughter and jokes also carry loose cigarettes from table to table, unashamedly pushing them on all they meet – old and young, some very young. We despair. The more who take it up, the more fashionable it becomes and so big tobacco’s insidious recruitment rolls on.
Tobacco is arguably the most efficient man-made ‘murdering machine’ of non-combatants the world has known. Yet just as some countries are turning the tide, the peddling of this poison in many emerging economies is growing exponentially. Myanmar ratified the WHO Framework Convention on Tobacco Control in 2004, but we see no impact of it in the daily rituals of the tea houses. Does opening up to the world also have to mean welcoming the tobacco industry to the country?
As a tobacco warrior from the mid-1980s in Australia, I remember well the battle to get the first legislation in the world to ban tobacco advertising and hypothecate cigarette levies for health promotion purposes through the upper house of the Victorian state parliament. I personally witnessed Bruce Redpath (a noted Cancer Council supporter and prominent Australian business leader) phone the three main funders of the political party which were threatening to block the legislation. I listened to these leaders agree that “no one in business worth their salt would work for a tobacco company today. It is time to act?”
Act they did, and in 1987 the legislation passed into law. The Victorian Health Promotion Association – VicHealth – was born, and today the state of Victoria is a global leader in tobacco control. In 2001, Myanmar’s neighbour Thailand took the same step and established the Thai Health Promotion Foundation. Thailand’s achievements in tobacco control in the 13 years since show that the rise of the tobacco epidemic is not an inevitable and unavoidable by-product of economic development.
As we sip on our super-sweet coffees in our now favourite Mandalay tea house and look around us at the unfettered tobacco promotion, we can only hope that leaders like Bruce Redpath will emerge with the intellectual and moral courage to say it’s now time to act to control tobacco promotion in Myanmar; to stop the epidemic in its tracks.