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’.

"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.

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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.

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

Senegal has launched its first national mass media campaign about the harms of tobacco. Developed by the Ministry of Health and Social Action and World Lung Foundation, the campaign graphically depicts the tar that collects inside an average smoker’s lungs. It is hoped that the campaign will empower citizens with new knowledge, and also spur advocacy and government policies to protect citizens from tobacco.

Called ‘Sponge,’ the campaign will air on TV, radio, outdoor venues and SMS for eight weeks.  It was tested rigorously in Senegal, and is based on campaigns previously aired in Australia, China, India, Mauritius, Russia, the United States, and several other countries. Currently, three percent of all male deaths in Senegal can be attributed to tobacco use; a number set to skyrocket as the tobacco industry increases its efforts to addict more people to its products.

Across Africa, tobacco industry activity is booming. Women in Africa, who have a relatively low smoking prevalence compared to other regions of the world and are therefore seen as a growth market, are aggressively targeted by the industry. Initiation among young people is also a concern; according to The Tobacco Atlas, almost 20% of youth in Senegal report having an item with a tobacco logo on it, with even higher percentages in Chad (30%), Niger (30%) and Mauritania (28%). This data suggest young people are being subjected to aggressive marketing to addict a new generation of users.

The campaign television ad (in French) can be viewed from the World Lung Foundation website.

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.

Pascal Diethelm

OxyRomandie, Switzerland

On 28 February 2013, British American Tobacco (BAT) published their preliminary results for 2012 and issued an accompanying news release in which the chairman of BAT expressed his satisfaction that BAT was able to deliver “strong profit growth in 2012, achieved through good pricing and an outstanding improvement in operating margin”. The press has mostly relayed uncritically BAT’s clamouring of their soaring profits – see for instance here.

One thing BAT did not highlight is the good news, from the tobacco control viewpoint, that this profit increase was exclusively achieved through pricing mechanisms in the context of a declining market across all regions of the world, as shown below:

(Bns = Billion sticks; EEMEA = Eastern European, Mediterranean and African region)

Overall, the number of cigarettes sold by BAT has decreased by 1.56%. Furthermore, although the rate of decrease varies considerably from one region to the other, it is notable that a decrease was observed in all regions of the world. The high decline of smoking in the European regions is not compensated by an increase in other parts of the world.

This is good news and shows a trend that is likely to become more marked in coming years as the full effect of the Framework Convention on Tobacco Control (FCTC) is seen. With a decrease of 1.56%, and expecting even greater decreases in coming years, achieving the WHO Global NCD Action Plan target of 30 x 25 (30% reduction of overall smoking prevalence by 2020) becomes within reach. A reduction of 1.56% for 13 consecutive years would translate into an overall reduction of 18%, assuming a linear correlation between prevalence and number of cigarettes smoked. To achieve the 30×25 target, an overall annual reduction of 2.8% in smoking prevalence is needed.

Of particular note is how BAT’s profit increase is distributed over the regions. At 7.4%, the Western European region contributes very little. By far the greatest contributor is the EEMEA region, which is responsible for 44% of the profit increase. This is also where the price of a pack of cigarettes is lowest, i.e. where the industry has the highest potential for price, and thus profit, increases. This illustrates one interesting aspect of the cigarette business. Relying on addiction which creates a rather inelastic demand for their product, the industry uses tobacco as a means of siphoning money from the pocket of addicted smokers in poorer countries to move it into the pockets of investors in rich countries. And they can increase the flow of money at will simply by enlarging the size of the tube!

The US Food and Drug Administration (FDA) has announced that Mitchell Zeller, J.D., will assume the role of director of the Center for Tobacco Products on March 4, 2013. He will replace Dr Lawrence Deyton, who, as the first head of the Center for Tobacco Products, led the unprecedented charge by the FDA to implement the Family Smoking Prevention and Tobacco Control Act. The Act gave the federal government authority to regulate tobacco for the first time.

Legacy President and CEO Cheryl Heaton has warmly welcomed the FDA’s decision to appoint Zeller, who is an accomplished lawyer, tobacco control strategist and advocate for public health. Zeller was the former associate commissioner of the FDA under David Kessler and previously served as health policy expert with Pinney Associates as well as Executive Vice President at Legacy during its formative years.

Zeller helped lead The Strategic Dialogue on Tobacco Harm Reduction (the Dialogue) among public health experts. “Zeller’s thought leadership and foresight on the regulation of tobacco and reducing smokers’ health risks will be an invaluable asset to the FDA as it moves forward with its tremendously important mission”, said Dr Healton.

Read the full legacy statement here.

Seems this business award committee forgot about all of Imperial’s sick, dying and dead customers. I wonder if the local community contributions included addicting children to tobacco and breaking up families? This latest award provides yet further evidence of the tobacco industry using corporate social responsibility programs to polish is tarnished image and avoid government regulation.

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Tobacco Reporter writes:

Imperial Tobacco’s operation in Poland has been handed a prestigious award by the nation’s leading business organisation.

The ‘Diamond to the Gold Statuette of the Business Leader’ was awarded in recognition of Imperial’s social and economic contribution to Polish society.

The award was made at the annual Grand Gala of Business Leaders held in Warsaw by the national Business Centre Club.

Imperial was chosen by a jury of leading business people who looked at how companies take care of their employees, contribute to local communities and engage with stakeholders.

The award, which builds on the gold statuette Imperial received last year, was accepted by Grażyna Sokołowska, corporate and legal affairs manager Poland.

“I’m delighted we’ve been recognised as a responsible business making a valuable contribution, which can only be achieved through the efforts of all our employees,” said Sokołowska.