Battling Big Tobacco: Physician activism vital on smoking's new frontiers

November 28, 2011

Orlando, FL - It's no coincidence that the small South American country of Uruguay had a physician as president when it began implementing some of the strongest tobacco-control policies in the world five years ago. Dr Tabaré Vásquez, an oncologist, became president there in 2005 and proceeded to turn the nation of just 3.5 million people into a leading example of how to try to curtail cigarette consumption.

He achieved this through methods that are widely acknowledged to work by those advocating for global tobacco control: banning smoking in public places; increasing taxation on and subsequently the price of cigarettes; banning advertising, sponsorship, and promotion by tobacco companies; restricting the use of misleading words on cigarette packs; and making smoking-cessation programs and products widely available.

But the tobacco industry fought back[1], with Phillip Morris bringing an international lawsuit against the government there, "not because Uruguay is an important market but because its policies could spread over the world," explained Dr Walter Reyes Caorsi (Casa de Galicia Hospital, Montevideo, Uruguay) during a session on global perspectives on tobacco control at the recent American Heart Association (AHA) 2011 Scientific Sessions . Although Vásquez is no longer president of Uruguay, his successor, José Mujica, says he plans to continue the strong tobacco-control policies established by his predecessor

Next in line to face the wrath of this industry—and a widely expected lawsuit—is likely the Australian government, which is hoping to enact, by the end of this month, a law that stipulates that cigarettes can be sold only in plain packaging[2,3]

Doctors as activists?

According to Reyes Caorsi and others speaking at the AHA meeting, cardiologists, other physicians, and health professionals must play a vital role in combating the tactics of tobacco companies.

Matthew L Myers

And that, Matthew L Myers (president, Campaign for Tobacco-Free Kids [CFTFK], Washington, DC) told heartwire at the meeting, means staying one step ahead of the cigarette companies, which will never stop attempting to fight those trying to effect change and which will keep pushing to expand their markets in any way they can.

"The evidence shows that restricting tobacco use is perhaps the most important way to reduce CVD globally," says Myers. But he notes that it is important for people to understand "that we are at very different stages around the world: in developed nations, we are beginning to see tobacco use decline among both men and women. But in low- and middle-income countries, we are seeing both very high rates of smoking among men and, even more disturbing, dramatically increased smoking rates among women."

And he warns that while the global public-health community's focus is on trying to reduce the number of male tobacco users in developing countries—where frequently the majority of men smoke—the tobacco industry is unashamedly targeting women and children in those nations, most of whom do not currently smoke but whom industry sees as ripe for the picking.

We have seen, where leaders of the health community become involved . . . that in fact they can counteract the tobacco industry.

A two-page Virginia Slims advertisement in Swahili links smoking to independence and beauty [Source: CFTFK]

"What we are seeing now in emerging markets we've seen for 80 years in the developed world. The move to make smoking glamorous, to make smoking part of a new freedom, a new independence, a new economic wealth among women, is found in every low- and middle-income country that is beginning to prosper."

According to Myers, health professionals have "huge political clout" that they don't often put to use. "We have seen, where leaders of the health community become involved, demand change, support change, speak out, that in fact they can counteract the tobacco industry. Doctors need to be talking to their public officials about the impact of tobacco use and supporting the policies that we know work. They need to be speaking to the media. They need to be talking to their patients about both direct smoking and secondhand smoke."

Johanna Ralston

Johanna Ralston (CEO, World Heart Federation) agrees. Observing that not every country is as lucky as Uruguay to have had a physician as president, she said, "One of our priorities is to further engage the cardiovascular community in this space, so please do get more involved . . . cardiologists have an important role to play."

Dr Hans Stam

Dr Hans Stam (CEO and executive director, Netherlands Heart Foundation) was equally as impassioned when he revealed the disaster that has befallen his country when a smoker became minister of health, rolling back a number of public-health policies limiting tobacco use. "Both the problem and the solution are outside the normal medical framework. But there is probably nothing we can do that will have a greater impact," he urged.

"We need to remember that the tobacco industry won't quit trying to change the perception of what smoking is really like," Myers emphasized. "The task for all of us is to make sure that before they get there, we get there."

US has still not ratified FCTC, the world's first public health treaty

In her talk at the AHA meeting, Ralston explained that 174 countries have now ratified the WHO Framework Convention on Tobacco Control (FCTC), which, she noted, is "the world's first public-health treaty and quite an extraordinary accomplishment, as we look back on where tobacco was 20 years ago."

But there is still much to be done, she stressed. "We still need countries to ratify it, including the US." Myers says the two other major countries that have not ratified the FCTC are Argentina and Indonesia. "I do not expect any of these three to ratify shortly," he told heart wire . In the US, President Barack Obama supports the convention, he says, but ratification requires a two-thirds majority in the Senate, "and that would be tough in the current US political climate." Indonesia, meanwhile, is a country where the tobacco industry is very powerful "and has the most backward tobacco-control laws among major nations." Argentina, at least, has focused on passing a strong tobacco-control law over the past two years and succeeded, Myers notes, but it's not clear when it will consider the FCTC, he says.

Smoke-free public spaces are a key component of FCTC, but as several speakers noted, success has been mixed. Only around 20 countries worldwide reach the "gold-standard" definition of smoke-free, where smoking is prohibited in all enclosed public places and workplaces, including bars, restaurants, and public transport, Myers noted. But as Ralston observed: "For Ireland's pubs to go smoke-free shows that anything in the world is possible."

And on the issue of packaging, Myers said the decision to move to plain packaging in Australia has been a direct response by the government to tobacco-industry attempts to thwart any kind of restriction on tobacco marketing. When the government banned the use of terms like 'light' and 'low tar,' manufacturers responded by changing their packages to make them appear more beautiful, he said. Australia's response, he says, "is an extraordinarily important step forward."

A similar thing happened in Uruguay, as detailed by Reyes Caorsi. After Uruguay banned similar terms on cigarette packs, the tobacco industry instead decided to color-code the cartons and sent specific instructions to retailers to say, for example, that light blue was now the former 'light.' In response, the government increased the size of its warning labels and restricted the number of variations of each brand to one. Industry reacted by suing the government.

However, Myers stresses that "countries like Uruguay and Australia have demonstrated that when governments act, we can dramatically decrease the number of people who smoke and die."

Opening a gold mine: Industry targets women in emerging nations

Around 20% of the world's one billion smokers are women, says Myers, "but the rate varies dramatically from country to country." In developed countries, where 22% of women smoke, "we are at a different stage of the pandemic compared with low- and middle-income countries, where that number is only 9% at the present time." And adolescent girls in developing nations still smoke at rates way below the averages seen in developed countries, he noted.

"When we look at low smoking rates among women in low- and middle-income countries, we think this is something we have to preserve, but when the tobacco industry looks at them, they see something very different. They see a population that isn't yet smoking, a future growth market," he explained in a chilling presentation at the AHA meeting.

A cigarette advertisement in Georgia, targeting women [Source: CFTFK]

Displaying slide after slide of advertisements of cigarette packs aimed exclusively at women—depicting smokers as sexy and independent—he used the example of Russia after the fall of communism to illustrate just how rapidly things can change.

During the mid-1980s, less than 5% of women in Russia smoked; "it was cultural anathema to them," Myers explained. But by the mid-1990s, "just a few years after Western-style marketing was introduced," this figure was up to 12%. By 2001 the figure was 15.5%, and in 2009 that number was 21.7%.

"Walk down a street in Moscow now and you will see women smoking long, thin, white cigarettes. How did that happen? It wasn't a coincidence. The tobacco industry redesigned their advertising, their packages, specifically to target that population. To make smoking look like the perfect way for women to express their new identity in a new world. A new independence. A new glamour. A new freedom."

And make no mistake, says Myers, cigarette companies are keen to replicate the Russian experience in every emerging market in the world. "Where we go could be a lot worse than where we've been," he observed.

"When we look at China and think our task is to get male smoking rates down from the majority to a low number, we'd better not forget the tobacco industry is taking the 2.4% [of Chinese women who smoke] and driving it up. Not by 10%, not by 100%, not even by 1000%, but by multiples of that. And who wins that war in China is going to have a lot to do with how many people in this world die from tobacco use over the coming century."

Blatant targeting of children as the next generation of smokers

Myers then went on to discuss an even more sinister practice: cigarette manufacturers' attempts to lure children as the next generation of smokers. Every day, around the world, 80 000 to 100 000 young people become addicted to cigarettes, he notes. "The tobacco industry has said for over 50 years that it doesn't want a single kid to smoke, that it has never designed an advertising campaign to market to children. They must think we all don't know what's going on."

Marlboro sponsorship of school uniforms in China [Source: CFTFK]

Examples of initiatives that blatantly target children include Marlboro sponsorship of school uniforms in China and the names of cigarette brands on basketball courts in Africa, he explained. And in Indonesia, the use of cartoon characters to advertise cigarettes, sponsorship of rock concerts, and, perhaps most disturbingly of all, cigarette packs featuring giraffes, zebras, lions, and other animals on the front.

"If we don't think that the pack is important—and therefore the action taken by Australia to go to plain-paper packaging—all you have to do is look at these packs in Indonesia, which I often think of as Disneyworld for the tobacco industry, because virtually anything is allowed if you can have packs like this."

He continued: "We have seen what the magnitude of the problem is. We have seen the tobacco industry undermining governmental systems designed to protect our families and our individuals. We've seen their willingness to attack countries where leaders act strongly. There is no place [the tobacco industry] won't go. They do not have a conscience in what they are doing. Young, vulnerable, uneducated young women and children are their target market for the future."

On the flip side, it's also been seen that collaboration between physicians, governments, and health activists can "change that picture" he said, citing the WHO FCTC and the political declaration issued by the general assembly of the UN in September, as well as the stance taken by countries such as Australia and Uruguay.

Cigarette packaging in Indonesia features animals and soccer balls [Source: CFTFK]

If we don't think that the pack is important, all you have to do is look at these packs in Indonesia, which I often think of as Disneyworld for the tobacco industry.

And the key message for doctors, says Myers, "Is that if we all don't become involved, then the tobacco industry wins. That's the lesson we've seen around the world. Strong action depends upon the health leaders of our nations—whether they are focused on cardiovascular disease, cancer, or any other disease—stepping up and demanding the right thing from our politicians and equally our politicians doing the right thing, standing side by side.

"We are all used to solving our healthcare problems in our research laboratories, in our hospitals, in our clinics," he adds. But this is a problem "we have to solve by becoming engaged in our society and the political discussion. It is someplace we are not comfortable historically, but it is the one way we have to make sure that the billion people forecast to die this century from tobacco use [do not]."

The Asian perspective: Look to Singapore for guidance

Providing a snapshot of the current status of smoking in Asia during the AHA symposium was Dr Dayi Hu (People's Hospital, Beijing University, China), who explained that, while smoking rates do vary, more than half of all males smoke in many countries in Asia.

And physicians are not immune to this addiction either, he noted, adding that China is probably the worst country in the world for physicians smoking. A staggering 46% of Chinese doctors smoke and, perhaps even more amazingly, 30% of cardiologists still do, he noted.

Currently the use of services and medication for smoking cessation is "very limited" in China and other Asian nations, said Hu, "and doctors don't do much to improve this situation."

Secondhand smoke is also a massive issue in Asian countries, Hu explained; many families live in houses with poor ventilation. And smoking means that funds that are needed to buy food and other staples are instead diverted to purchase cigarettes, Myers noted, citing one study from Indonesia that showed that 11% of disposable income goes to pay for the head of the household's smoking habit. Those numbers will only go up if aggressive industry efforts to glamorize smoking among women—both in Asian nations and among Asian minorities in Western countries—are successful.

[Source: CFTFK]

The adoption and implementation of other important components of tobacco control vary among different countries in Asia, but for the most part there remains a lot of room for improvement, Hu noted. In general, cigarettes are still very cheap in most places there, because taxation is low, regulation of cigarette packaging is variable, and bans on tobacco advertising, promotion, and sponsorship, where they exist, could be strengthened. And legislation to protect people from tobacco smoke in public places not only needs to be enacted but to be implemented, he stressed.

Myers notes that India is the "worst example" of putting smoke-free legislation in place but not enacting it. Despite endorsing what was widely touted as the world's biggest smoking ban in 2008, "no one takes any notice." However, there is hope, he says, explaining that in huge countries, such as India and China, the best way to approach this issue is often to work with individual cities. "We've been doing a lot of work in India, and in a number of cities, including Mumbai, Delhi, and Chennai, we are beginning to see real change."

Hu agrees, noting that a few cities in China, such as Shanghai and Hangzhou, have enacted laws on smoke-free environments, prompted by the example of Beijing, which pioneered this approach for the 2008 Olympics, alongside its refusal to accept tobacco sponsorship for those games and for the Asian games that followed. Hong Kong is also setting an excellent example to the rest of China, with taxes and the price of cigarettes increased there and the introduction of legislation on smoke-free public places.

Other success stories in Asia include Malaysia, which has significantly increased taxation on cigarettes and where there have been warning labels on packaging since 2010, and Taiwan, which enacted the Tobacco Prevention Act in 2009. But Singapore is perhaps the best example of all, not just in Asia but globally, said Hu, with a national tobacco-control program and a smoking rate "of 12.4%, one of the lowest smoking rates in the world."

"Minister of death" takes Holland back to the dark ages

Stam, meanwhile, warned attendees at the AHA meeting that Europe is by no means out of the woods when it comes to tobacco control. "Europe isn't doing very well, especially if we look at national policies on packaging and labeling, the way they attract smokers, and only a small message that smoking is deadly," he noted, adding that tobacco-dependence treatment also takes a back seat in a lot of European countries.

German cigarette advertisement [Source: CFTFK]

And using the Netherlands as an example, Stam explained how quickly things can turn around if the political will to tackle tobacco addition suddenly wanes. The result is a horror story.

At the end of the 1990s, the prevalence of smoking in Holland was about 35%, he explained. "The government was active, there was a millennium campaign, and in 2004 legislation concerning smoke-free work places and reimbursement for smoking cessation was introduced." And in 2006, an alliance of health charities, backed by the previous government, aimed to reduce the number of smokers from what was then 28% to 20% by 2010, he noted.

"But then a disaster came over Holland, with an extreme right-wing government and a smoker as minister of health, Edith Schippers. We call her minister of death." Among Schippers's first moves, said Stam, was to state that adults should have a free choice to smoke: "the state is not a nanny." Then last year, she partially reversed the smoke-free legislation, "so now in almost 50% of all cafes and bars people smoke again." From 2012, she has decided to end reimbursement for pharmacological tobacco-dependence treatment and also plans to end mass-media and governmental campaigns for tobacco control, including the cessation of support for the leading antitobacco group, STIVORO, he added.

A disaster came over Holland, with a smoker as minister of health. We call her minister of death.

"And she has declared already that she will give no support to or implement the European product directive [regarding] further tax increases on tobacco." In addition to this, "the tobacco industry is very, very active and clever in lobbying," Stam notes.

"But do we sit still in the Netherlands? We do not." The first move has come from an activist organization, Clean Air Netherlands, which has now sued the minister of health, stating that her decision to exempt small bars and cafes from the smoking ban contravenes the tobacco act and the WHO FCTC, to which the Netherlands is a signatory. Many other actions are planned, he noted, including the presentation of an important report by January 2012.

"Let's hope we can turn around what is happening in the Netherlands," he concluded.

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