Smoking gun

The WHO stance that tobacco is the premier killer helps the World Conference on Tobacco or Health declare war on the industry.

recently in Singapore

Dr Margaret Chan, who has been re-elected Director-General of the World Health Organisation (WHO) for a second term, proved her mettle in the keynote address she gave at the 15th World Conference on Tobacco or Health (WCTOH), held in Singapore from March 20 to 24. (Her present term will run through June.)

The conference, organised by the WHO and the Singapore Health Promotion Board, was like a declaration of war on the tobacco industry. The pugnacious Director-General launched into her attack at the very start of the conference, calling the industry a ruthless and devious enemy [that] has changed its face and its tactics. The wolf is no longer in sheep's clothing, and its teeth are bared.

She was referring to the tobacco industry's aggressive legal action against certain signatories to the WHO Framework Convention on Tobacco Control (FCTC). The convention, which was ratified and came into force in 2005, has 168 signatories, including India, who are committed to implementing the treaty's articles. According to the Conference of Parties, the governing body of the FCTC, the convention represents a paradigm shift in developing a regulatory strategy to address addictive substances; in contrast to previous drug control treaties. It asserts the importance of demand reduction strategies such as price and tax measures to reduce the demand for tobacco and non-price measures such as regulation of tobacco product disclosures; tobacco advertising, promotion, sponsorship and packaging; regulation of contents of tobacco products; labelling of tobacco products; and supply issues such as illicit trade in tobacco products and sales to and by minors.

The convention is a threat to the tobacco industry because its signatories cover almost 90 per cent of the world's population. Margaret Chan asserted: If safety from tobacco lies in numbers, we have them. But, unfortunately, the numbers are not adding up. Of the 168 signatories, only four have carried forward the articles of the convention to the extent where it makes a difference, and it is these countries that the tobacco giants are now targeting with legal action.

The tobacco industry has, until now, managed to undermine the tobacco control measures by employing a combination of weapons such as direct and indirect political lobbying, contributing to campaigns, financing research, attempting to affect the course of regulatory and policy machinery, and engaging in social initiatives to promote the tobacco industry. Ever since the convention came into force, tobacco companies have launched legal action against countries that have taken steps to implement its wide-ranging provisions.

Australia, Uruguay, Turkey and Norway are among the signatories that have taken on the powerful tobacco industry. These countries have gone beyond implementing Article 11 (packaging and labelling of tobacco products). According to Article 11, within three years of joining the convention, the signatories must have health warnings that cover at least 30 per cent (preferably 50 per cent) of the visible area on a packet. Article 5.3 (the protection of public health policies with respect to tobacco control from commercial and other vested interests of the tobacco industry) gives countries the right to take such actions.

Australia has also taken the lead in implementing Article 13, which calls for a comprehensive ban on advertising, promotion and sponsorship of tobacco products. In November 2011, the Australian government took Article 11 to its ultimate end. It became the first country to push through a tough law against cigarette promotion by adopting a plain-packaging legislation which bans tobacco companies from displaying their logos or brand names on the packet. The law takes effect on December 1, 2012, from which date cigarettes will be sold in packs that are a standard drab dark brown colour with a matt finish. The pack will be dominated by large graphic images and health warnings of tobacco-related diseases. These will occupy 75 per cent of the packaging area. Brand logos, symbols and other images or promotional text will not be allowed, but cigarette companies will be allowed to print their name and brand in a standard colour, position, font size and style.

On the very same day that the law was passed in Australia, Philip Morris Asia's Hong Kong office filed a formal notice of arbitration under the Australia-Hong Kong Bilateral Investment Treaty, claiming a violation of the treaty.

Separately, the tobacco industry sued the Australian government in a domestic court saying that the legislation breached the Australian Constitution since its actions could result in the acquisition of property (that is, brand names) without compensation. Rejecting the claim, Professor Jane Halton, Secretary, Australia's Department of Health and Ageing, said: Given the threat to profits from plain packaging, we are not surprised by the reaction of the industry. In Australia, we have encountered these tactics for more than four decades, but the efforts now being made to stop our plain packaging law are extreme.

She said that ever since the announcement for plain packaging was made in April 2010, her department had received no less than 64 Freedom of Information [FOI] requests relating to tobacco plain packaging, 53 of which are from the tobacco industry. The strategy is clear. Processing all those requests requires time and effort.

We have had to examine hundreds of files and make decisions on tens of thousands of documents for potential release to the tobacco industry and the public. In addition, we have had to deal with numerous reviews of FOI decisions, as well as formal complaints and appeals lodged by the tobacco industry, she said. Funds and resources that could otherwise be used to implement the government's reforms in tobacco control, particularly plain packaging, are tied up. Giving an example, Jane Halton said, One particular set of FOI requests from British American Tobacco Australia cost the department over $643,000 to process. However, under Australian FOI laws, the department was only able to recover around 20 per cent of those costs.

The tobacco industry has retaliated by launching well-oiled campaigns. Jane Halton enumerated them. In 2011, Philip Morris launched the I deserve to be heard campaign, which encouraged cigarette smokers to speak out against tobacco control. Imperial Tobacco Australia started the Nanny State campaign specifically against the plain-packaging law. Using mass media advertisements, it pushed the idea that smoking was a matter of free choice.

Jane Halton also said that front groups were being formed to confront governments, to sow conflict and polarise opinion. For example, during the 2010 federal election, British American Tobacco Australia, Philip Morris and Imperial Tobacco Australia co-funded a campaign run by the Alliance of Australian Retailers. This alliance was specifically formed to fight the government's plans to introduce plain packaging of tobacco products and purports to represent thousands of ordinary Australian shopkeepers. Seemingly undeterred by all this, Jane Halton said, The more the tobacco companies fight, the more we know we are on the right track.

Tobacco companies are pushing for representation on government committees formed for vetting policy and framing legislation on tobacco. The WHO Director-General has a word of caution against this: Don't fall into this trap. Doing so is just like appointing a committee of foxes to look after your chickens.

Australia's legislation has attracted interest outside the country. In March, Ukraine (followed by Honduras in April) officially requested consultations on the law with the World Trade Organisation (WTO). The consultation, or formal initiation of a dispute, gives the parties an opportunity to discuss the matter and to find a satisfactory solution without proceeding further with litigation. After 60 days, if consultations have failed to resolve the dispute, the complainant may request adjudication by a panel. Consultations are currently ongoing.

Both countries have claimed that Australia's legislation is an unnecessary obstacle to trade. While tobacco-producing Honduras could have a valid point since it trades tobacco with Australia, Ukraine's request for consultation is not easy to explain since there is no trade in tobacco or tobacco-related products between the two countries. However, experts participating in the Singapore conference theorised that since all tobacco giants had a presence in Ukraine it was possible that the Ukrainian government was urged to challenge Australia in the WTO. It is worth noting that last year Ukraine's cigarette production was close to 100 billion, which is a sizable contribution to its economy.

Although Australia's is the most recent, most high-profile and certainly the most determined and united effort at battling the tobacco industry, it was a measure adopted by Uruguay in 2010 that must have truly angered Philip Morris International. This tiny country (just 174,000 square metres) with a gross domestic product (GDP) that is about one-third the market capitalisation of Philip Morris (makers of Marlboro cigarettes) insisted that Philip Morris depict pictures of cancer victims on their packets. Philip Morris objected, saying that the photographs would partially cover their logo and result in expropriation of profits without compensation and would be in violation of Uruguay's free trade agreement with Switzerland (where Philip Morris' operational headquarters is located). Philip Morris' lawsuit could cost Uruguay millions of dollars if it loses, but the country has received support from 171 nations, the WHO and anti-tobacco organisations. The Uruguay campaign against smoking was started by President Tabare Vasquez, an oncologist by training. His successor, President Jose Mujuica, is continuing the battle.

While countries such as Norway and Turkey have also displayed readiness to take on the tobacco industry, it is the smaller ones that will suffer the legal action the most. Margaret Chan rightly pointed out that Big Tobacco can afford to hire the best lawyers and PR firms that money can buy. Big Money can speak louder than any moral, ethical, or public health argument, and can trample even the most damning scientific evidence.

Spate of studies

Explaining why plain packaging has been adopted with such fervour by anti-tobacco activists, Jane Halton said packaging is one of the last forms of tobacco advertising and hence must be removed and replaced with pictorial representations that would act as a deterrent to smoking. Doubts have been expressed about the effectiveness of packages that display grisly photographs of cancer victims, testimonials of victims or families and didactic text. The volume of dissent was enough to generate a spate of studies.

Here are the findings of two recent research papers on pictorial warnings. Researchers James F. Thrasher, Edna Arillo-Santillan, Victor Villalobos, Rosaura Perez-Hernandez, David Hammond, Jarvis Carter, Ernesto Sebrie, et al, asked the question, Can pictorial warning labels on cigarette packages address smoking-related health disparities? They conducted field experiments in Mexico to assess pictorial warning label content. Their findings, published in Cancer Causes & Control, an International Journal of Studies of Cancer in Human Populations (Volume 23 Supplement 1), show that pictorial health warning labels (HWL) with educational text had an equivalent or significantly higher credibility, relevance, and impact than pictorial HWLs with testimonial forms.

Warning labels

Results also showed that didactic forms were consistently rated higher than testimonials among participants with higher education, whereas the difference between didactic and testimonial narrative forms was weaker or not statistically significant among participants with lower education. In conclusion, the researchers write: Pictorial HWLs with didactic textual forms seem to work better than those with testimonial narratives. Future research should determine which pictorial HWL content has the greatest real-world impact among consumers from disadvantaged groups, including assessment of how HWL content should change to maintain its impact as tobacco control environments strengthen and consumer awareness of smoking-related risks increases.

In another study, conducted by David Hammond, James Thrasher, Jessica L. Reid, Pete Driezen, Christian Boudreau and Edna Arillo Santillan in 2011, again in Mexico, the importance of pictorial warnings was once again highlighted. The researchers wrote: Graphic depictions of disease were perceived by youth and adults as the most effective warning theme. Perceptions of warnings were generally similar across socio-demographic groups.

The studies also laid open new dilemmas, with cultural, linguistic and other considerations being thrown up. Clearly, a multi-design approach that addressed the specifics of various countries would reach out to the maximum number of smokers, which is what is being put into practice.

The WHO has taken an unyielding stance on tobacco, linking its consumption with the spread of non-communicable diseases, including cardiovascular disease, cancer, diabetes and respiratory disease.

Margaret Chan said, Tobacco use is the world's number one preventable killer. We know this statistically, beyond a shadow of a doubt. In a world undergoing economic upheaval, with populations ageing, chronic diseases on the rise, and medical costs soaring, tackling a huge and entirely preventable cause of disease and death becomes all the more imperative. We know that tobacco directly harms the user's health in multiple ways. We know that tobacco products kill their consumers. We know that tobacco smoking, like a drive-by shooting, kills innocent bystanders who are forced to breathe air contaminated with hundreds of toxic chemicals. We know what tobacco exposure during pregnancy does to the foetus, another innocent, blameless, and entirely helpless victim.

While the fight is by no means at an end, the mood of the anti-tobacco brigade has the upbeat feel of revolutions. And it is best summed up by Margaret Chan, who parodied the popular You've Come a Long Way, Baby advertisements of the Virginia Slims cigarette brand by turning it around and saying to the industry, We've come a long way, bullies. We will not be fazed by your harassment. Your products kill nearly six million people each year. You run a killing and intimidating industry, but not in a crush-proof box.

If that does not sound like throwing down the gauntlet, nothing does.