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.

Non-smokers should shun hotels operating partial smoking bans, advise authors

Non-smoking rooms in hotels operating a partial smoking ban don’t protect their occupants from tobacco smoke, reveals new research published online in Tobacco Control. [Thirdhand smoke and exposure in California hotels: non-smoking rooms fail to protect non-smoking hotel guests from tobacco smoke exposure Online First doi 10.1136/tobaccocontrol-2012-050824]

Non-smokers should give hotels that allow smoking in certain rooms a wide berth, say the authors, and instead choose completely smoke free hotels.

The researchers analysed the surfaces and air quality of rooms for evidence of tobacco smoke pollution (nicotine and 3EP), known as third hand smoke, in a random sample of budget to mid-range hotels in San Diego, California.

Ten hotels in the sample operated complete bans and 30 operated partial smoking bans, providing designated non-smoking rooms.

Non-smokers who spent the night at any of the hotels, provided urine and finger wipe samples to assess their exposure to nicotine and a cancer causing agent found specifically in tobacco smoke—known as NNK—as measured by their metabolites cotinine and NNAL.

The findings showed that smoking in hotels left a legacy of tobacco pollution in both smoking and non-smoking rooms. A partial smoking ban did not protect the occupants of non-smoking rooms from exposure to tobacco pollution.

Compared with hotels operating total smoking bans, surface nicotine and air 3EP levels were higher in both non-smoking and smoking rooms of hotels operating partial bans.

Surface nicotine levels were more than twice as high in non-smoking rooms of hotels operating partial bans as those of hotels operating total smoking bans (3.7 µg/m² compared with 1.4 µg/m²), while air levels of 3EP were more than 7 times as high.

Surface and air nicotine levels in rooms where previous guests had smoked were 35 and 22 times higher than those of rooms in hotels operating a total smoking ban.

Air nicotine levels in smoking rooms were significantly higher than in non-smoking rooms; and they were also higher 40% higher in non-smoking rooms of hotels operating partial smoking bans than in those operating total bans.

Similarly, hallway surfaces outside smoking rooms also showed higher nicotine levels than those outside non-smoking rooms.

Non-smokers who stayed in hotels with partial smoking bans also had higher levels of finger nicotine and urinary cotinine than those staying in hotels operating total bans. Urinary NNAL was also significantly higher in those staying in the 10 rooms containing the highest levels of tobacco pollutants.

“Our findings demonstrate that some non-smoking guest rooms in smoking hotels are as polluted with [third hand smoke] as are some smoking rooms,” write the authors.

They go on to say: “Moreover, non-smoking guests staying in smoking rooms may be exposed to tobacco smoke pollutants at levels found among non-smokers exposed to second hand smoke.”

Few countries have adopted a smoking ban that includes hotels, say the authors, but their findings “suggest that it is time to abandon smoke-free exemptions for hotels,” they write.

New hotels should operate total smoking bans to protect not only their guests, but also their employees, say the authors. In the meantime, they advise: “Guests who wish to protect themselves from exposure to tobacco smoke should avoid hotels that permit smoking and instead stay in completely smoke-free hotels.”

The contact author for the study is Dr Georg Matt, Department of Psychology, San  Diego State University, San Diego, California, USA. Email: gmatt@mail.sdsu.edu

Chris Bostic

Action on Smoking and Health (US)

http://www.ash.org

I wonder if Philip Morris International (PMI) researchers have studied the ‘length of public memory.’ If so, the resulting answer seems to be ‘about 15 years.’ That’s how long it has been since the Tobacco Institute closed its doors, after 40 years of obfuscating the science on tobacco addiction, disease and death. A key aspect of industry strategy to forestall meaningful regulation has always been to question the causal link between tobacco and disease.

PMI has just launched phase two of its sbv IMPROVER project (the title is short for “systems biology verification of industrial methodology for process verification in research”). The theme is “species translation challenge,” and PMI, in collaboration with technoogy giant IBM, will award three US$20,000 grants to scientists who can best poke holes in translating disease lab results in rodents to humans. In one online article very sympathetic to Philip Morris, the reporter states “not every smoker suffers all or any of those health effects, suggesting that a combination of environmental and genetic factors lead to disease.” This years project follows on the “diagnostic signature challenge,” in 2012 which gave a US$50,000 award for showing genetic markers for diseases linked to tobacco.

The main purpose of IMPROVER seems clear – remuddy the waters on the causal link between tobacco and disease. But they actually get much more. By enticing young researchers to compete, PMI pushes back against the trend among major universities to not do business with big tobacco. These researchers are also a natural recruitment pool for the next generation of scientists who are untroubled by the ethics of working with big tobacco. By linking with IBM, working with universities, and comparing the effort to legitimate scientific endeavors such as DREAM, PMI gains legitimacy among the scientific community.

Finally, IMPROVER is a rather brilliant example of corporate social responsibility marketing. Turning the purpose of the scheme on its head, PMI says its “number one objective is to do something about our dangerous products.” How can anyone argue with that? That’s not rhetorical – I invite responses on all the ways we can argue with that.

On a side note, is the name IMPROVER a subtle nod and affront to MPOWER?

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]

Rosanne Palmer, ASH Wales

In July 2012, on the same day that the National Assembly for Wales approved point of sale display bans for tobacco products in Welsh stores, the Welsh Government laid an amendment to Wales’ smokefree premises legislation to allow cast members to smoke on set for film and television productions. This move came despite 75% of respondents to the 6-week consultation in spring 2012 opposing such an amendment, a strength of feeling that has become increasingly evident as attempts to introduce the legislation have become more drawn out.

The creative industry claims it needs to compete with England, which has an exemption built in to its existing smoking legislation for the film and television industry to protect the “artistic integrity” of a performance. Yet these production companies are able to simulate a wide range of actions like drug taking, car crashes and shootings – so why should smoking, which kills 5450 people every in Wales, be any different?

A vote on the amendment was scheduled for the Assembly plenary in mid-October but a campaign to #keeptheban generated enough interest and concern to see the amendment referred to not one, but two, committees – Health and Social Care and Enterprise and Business – leading to a first for the Assembly, the creation of two sub-committees, sitting jointly and composed of equal numbers of members from both parent committees, to take evidence around the ban.

Committee hearings began in January 2013 with evidence from, amongst others, Cancer Research UK, the British Heart Foundation, ASH Wales and the BBC. The opposition of public health practitioners and supporters to the proposed amendment is clear, and the scientific research on the impact of second hand smoke was frequently referenced. Counter assertions about the loss of production investment to England have yet to be substantiated, with the BBC being forced to retract a claim that a story-line for prime-time UK hospital drama Casualty had to be dropped because it required filming a smoking scene.

Following three evidence sessions in January and February, with the report expected in mid-March, the announcement was made that there would be a further evidence session in June with both the Health and Enterprise Ministers, as well as the Chief Medical Officer for Wales and members of the Welsh Government’s executive creative industries units invited to give evidence. Despite the degree of opposition, the amendment has thus far refused to go away.

During a recent Welsh Government reshuffle, the most outspoken opponent of the amendment as chair of the Health Committee in the Assembly, Professor Mark Drakeford, was elevated to the role of Health Minister. Whilst this represents a potentially promising development for opponents of the amendment, it currently remains on the table.

If you are interested in finding out more about the #keeptheban campaign, please visit the ASH Wales website and sign the #keeptheban e-petition to register your opposition to the dilution of smokefree legislation in a country that was the first UK nation to call for a smoking ban and help  prevent Wales taking a step back in time.

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.

"I promise you, I will do everything I can to make sure you did not die in vain. I will tell the world your story, and the story of other people killed by tobacco. I will challenge the tobacco industry, the tobacco lobbyists, and the politicians who listen to them."

Replacement smokers are the lifeblood of the tobacco industry. What’s it like to treat the victims of this insidious industry? In this powerful TEDx talk, pulmonologists Pauline Dekker and Wanda de Kanter show the heartbreaking, but all too typical, journey of a lung cancer patient, explode the idea of freedom of choice, and highlight the tactics of selling death.

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.

————–

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.

Akihiro Nishi, Tetsutaro Matayoshi, Takahiro Shimizu, Masako Kinkozan, Ichiro Kawachi

At the end of January, a local newspaper company in Okinawa, Japan, Ryukyu Shimpo, published an opinion letter from a young reader, entitled “Cool Big Brother”.

The author, a first-year elementary school girl (aged 6 or 7) related a warm-hearted story of an affectionate granddaughter (herself) and a convenience store clerk (big brother). In the letter, she recounted how she had decided to prepare a surprise gift for her grandfather, who loves smoking. She went to the local convenience store and asked the store clerk to give her as many packs of cigarettes as her pocket money could buy. He convinced the girl that her grandfather would be just as pleased with the gift of one packet, and gave back her change. The girl concluded her letter with praise for him: “that big brother was really cool”.

The letter created considerable controversy, even among health professionals, with opinion divided along the lines of health concerns versus ‘excessive’ anti-smoking attitudes. Within a week, the newspaper company realised that the letter was a forgery and retracted it. The newspaper’s failure to spot the forgery came to light only after the local elementary school – which the girl supposedly attended – reported that no student with her name was enrolled there. The true author of the letter remains a mystery.

The case raises some interesting observations about smoking and social norms in Japan. It is illegal for under-age youth to purchase tobacco, and store clerks selling tobacco to minors can lose their jobs. Nobody at the editorial desk of the newspaper seems to have caught this, or the troubling consequences of a six year old child being able to purchase cigarettes. Indeed, the newspaper company decided to run this story as a heart-warming tale of a young girl’s love for her grandfather, ignoring the fact that cigarettes are a gift with deadly consequences.

It would appear that the social acceptance of smoking as an unremarkable norm in Japan meant the newspaper expected readers would enjoy the letter as an uncomplicated and touching story. These enduring social norms will continue to pose a challenge in progress toward lowering the high prevalence of smoking in Japanese society, and point to the need for health professionals to more effectively communicate the negative impacts of smoking on both individuals and society.

Author affiliations:

Akihiro Nishi, Masako Kinkozan and Ichiro Kawachi: Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, MA, USA

Tetsutaro Matayoshi: Department of Cardiovascular Medicine, Nephrology and Neurology, University of the Ryukyus, Okinawa, Japan

Takahiro Shimizu: Chibana Clinic, Okinawa, Japan

Masako Kinkozan: Osaka Head Office, The Asahi Shimbun, Osaka, Japan