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Sunday Interview: Dr Mackay, tobacco industry’s worst nightmare

ANTI-TOBACCO advocate Professor Dr Judith Longstaff Mackay has been identified as ‘one of the three most dangerous people in the world’ by the industry. She was instrumental in developing the World Health Organisation’s Framework Convention on Tobacco Control. In her recent visit to Malaysia, she shares her experience campaigning against tobacco in Asia since 1984.

“I HAVE been described as a ‘psychotic human garbage, a gibbering Satan, an insane psychotic, power-lusting piece of meat, Hitler and a nanny’ and they (the tobacco industry allies) threatened to destroy me. But such threats and offensive words never once diverted me from my cause,” says Professor Dr Judith Longstaff Mackay.

Dr Mackay, 73, wears many hats. The World Health Organisation (WHO) senior policy adviser is also senior adviser to Vital Strategies, part of the Bloomberg Initiative to Reduce Tobacco and director of the Asian Consultancy on Tobacco Control.

Her recent visit was part of her capacity as a visiting professor at the University Malaya Centre of Addiction Sciences.

A recipient of British Medical Journal Lifetime Achievement Award (2009) and a Special Award for Outstanding Contribution on Tobacco Control (2014), she has published 200 papers, and addressed over 460 conferences on tobacco control.

Dr Mackay has received many international awards in recognition of her contribution on tobacco control. She was selected as one of Time’s 60 Asian Heroes (2006) and of Time’s 100 World’s Most Influential People (2007).

Question: Born in Britain, you moved to Hong Kong in 1967 after earning a medical degree from the University of Edinburgh in 1966. What led to your resignation as a physician in 1984, and then becoming a leading campaigner and advocate for tobacco control for the last 30 years?

Answer: I had a complete career change from cure to prevention and there were three main reasons for making the shift.

First, when I was working in a hospital in Hong Kong, we had a maxim on our male medical wards that every person we admitted was a smoker with tobacco illnesses, like heart diseases, cancer and chronic chest problems, which were often too late and too advanced to be cured.

I realised we had to go a step “higher upstream” to prevent this rather than merely providing the ambulance services at the end-stage.

I came to feel that hospital medicine was important but it works like a band-aid in comparison with prevention.

You may be able to save hundreds of lives in a lifetime in hospital medicine, but millions of lives could be saved if you work in prevention. It is a completely different ball game, and yet the money, prestige and attention all go to curative medicine; and that is similar around the world.

Second, was the realisation that although women’s health those days was defined very gynaecologically, more women were being killed by tobacco than by every method of contraception combined. I was particularly concerned that the tobacco industry was enticing women with promises of beauty, fame, emancipation and freedom.

The third reason was that the tobacco industry felt Asia was theirs for the taking.

They said it themselves — when asked about their future in the 1980s, “What do we want? We want Asia”.

Q: Why did the tobacco industry had their eyes set on Asia?

A: They wanted the huge populations and the large number of men already smoking who could be persuaded to smoke their brands of cigarettes.

They galloped into Asia with the dream of converting the 60 per cent of men who smoked local cigarettes to switch to international brands, and the second dream of persuading Asian women to start smoking. If this happened, their markets would be enormous.

It would not matter if every smoker in Britain stopped smoking tomorrow if they could capture the massive Asian markets.

Also, Asia was becoming more affluent, so, it was easier for people to afford cigarettes.

Thirdly, when I wrote an article in the South China Morning Post on banning cigarette advertising, a tobacco giant came down on me and labelled me as “entirely unrepresentative and unaccountable”.

The tobacco industry claimed that they were the best source of information on tobacco and they even said it has not been proven that “illness was actually caused by smoking”.

I was so outraged that it was just one of those tipping points in life in 1984. Everything came together and I realised that I really had to work on prevention rather than cure.

Ever since, I have been working principally with governments on the policy level to try and get the tax and the laws in place in tobacco control.

Q: You are known as one of the three most dangerous people in the world by the tobacco industry. What do you have to say about this?

A: Well yes, I’m proud of that. The reason that I got that title was essentially location. I happen to be in Asia and the tobacco companies wanted Asia. They saw this region as their future, but I set about thwarting their goals.

I went early on to countries like China, Indonesia, Malaysia, Mongolia, Vietnam and Cambodia and more recently to North Korea upon learning that British American Tobacco had gone into the country to get laws in place.

Q: In campaigning against tobacco use, what are some of the challenges you have faced?

A: I have had many problems, and was subjected to verbal abuse and even had death threats from allies of the tobacco industry.

Twice, I was threatened by the tobacco industry publicly, saying they would take me to court.

Nothing came of it, so it was either an attempt to intimidate me or to cast doubt on my credibility in the minds of the public.

In a television interview in South Africa, I openly said “I’m not a suicidal type, and if I were to be found knocked down by a bus, you need to find out if the tobacco industry is behind it before you look anywhere else.” And the industry was apparently furious with me for saying that.

However, their tactic now is not so much to attack people individually, but to threaten governments.

They threaten them under Constitutional Law on the rights of their products to advertise, and on freedom of speech and they attack them under trade treaties.

This is intimidating to governments and it can cost anything up to US$50 million (RM214 million) to fight these threats.

Q: You were one of the key persons in formulating the Framework Convention on Tobacco Control (FCTC), the first international treaty on public health. Malaysia is currently drafting the Control of Tobacco and Smoking Bill after lobbying for it since 2004 and they have sought your expertise. What do you have to say about this?

A: If you look at Malaysia and Hong Kong, many of the things that these two jurisdictions have done in the last 30 years are similar, yet Hong Kong has managed to half its male smoking rate.

Hong Kong is down to 10 per cent smokers now, whereas prevalence rates in Malaysia have not really decreased (at around 22.8 per cent). I understand it is not something that can be done overnight.

But the fact that the prevalence has not decreased is either because the excise tax imposed on cigarettes is not high enough, or that the laws that have been passed are not being enforced. In the case of the tobacco bill, the tobacco industry has been an unseen hand behind the scenes.

Q: The Health Ministry plans to increase prices of cigarettes from RM17 to RM21.50 in the near future to deter people from smoking. Several industry players were quick to say that increasing the tax would only lead to increased sales of illicit cigarettes. Is this true? What is the link between the increase in excise tax and contraband cigarettes?

A: There is zero truth in this. This sounds to me suspiciously just like what the tobacco industry would say. Economists, tax, finance and customs officials know, or they should know, that putting up a tobacco tax is not related to any increase in smuggling.

Our Customs chief in Hong Kong, for example, had said quite categorically there is no relationship between the amount of tax that is put in place and smuggling, and that is the position of the WHO too. But the tobacco industry keeps repeating it so often that some governments have come to believe it.

This is one of their tactics. A United States-based non-governmental organisation (NGO) has been going around the world, saying “don’t put up the tax, otherwise, there will be a rise in illicit cigarettes”. What many governments do not realise is that it is funded by the tobacco industry.

Q: WHO proposes that the tax imposed on cigarettes should be at least 75 per cent of the retail price. How efficient would this be in reducing smoking prevalence particularly among Malaysia’s young as compared with other measures, such as school education programmes?

A: Ten experts from around the world were present at a conference held in Hong Kong and, each speaker was asked “If you have one thing to do in tobacco control, what would that be?” and every single one said “tax”. This is because higher prices make cigarettes unaffordable to young people.

Taxation is the most effective approach to controlling the spread of tobacco. Creating smoke-free areas is the second measure, followed by things like advertising bans and smoking cessation.

Some people say health education in schools is crucial. Certainly, everybody likes health education, but it has not been proven effective in bringing down the prevalence of youth smoking.

And you can tell it is not effective because the tobacco industry does not oppose it. They oppose tax increases, plain packaging and smoke-free areas. And because the tobacco industry fights them, we know these are the measures that work.

Q: What needs to be done to improve our health education programmes at schools?

A: School health promotion programmes do not work because traditionally they say that if you smoke, you will get cancer when you are 60 years or heart attack when you are 70 years. If you are only a 11-year-old child, it is totally meaningless.

We need to do much more to revitalise and revamp health promotion and health education. Smoking and non-smoking youth have, in fact, the same level of health knowledge about the harms of smoking. The difference between the two groups is whether they think smoking is cool or a dirty expensive habit.

We have got to make it attractive to be a non-smoker in the teenage years.

Q: The Control of Tobacco and Smoking Bill currently being drafted would see the minimum age for buying cigarettes raised to 21 years old, ban on displaying tobacco products and making it illegal to smoke in vehicles with children inside, among others. How effective would this be in tackling smoking prevalence?

A: (People aged) 8 to 23 years is a vulnerable period. If you can stop children from smoking at this age, they are less likely to smoke. Whereas before that, they do not have the kind of mature judgment to analyse what it will mean to actually smoke.

The tobacco industry is very interested in youth and young adults because one has to only smoke 100 cigarettes and he or she will become lifelong smokers. It is so addictive.

Q: Besides health effects, what are the other impacts of cigarette smoking to the country and its people?

A: Two out of every three smokers die from cigarette smoking, so, you are losing skilled workers. One in every three fires in the world is caused by careless smoking.

There is also loss of productivity. Smokers go out for seven minutes to smoke. So, that’s seven minutes every time they smoke. Smokers are sicker and die on average a decade before non-smokers, so families lose their bread-winner.

There are medical and health costs. There is smoke damage to buildings and fabric.

And then there is a massive cost of cleaning up all the litter, billions of cigarette ends, packets, matches and lighters that are discarded every day in the world.

The tobacco industry claims that tobacco control would harm workers and farmers. This is not true. We have got so many projects now, including right in the heart of tobacco-growing in China showing that if farmers grow alternative crops they actually earn more.

The second fallacy is that if restaurants go smoke-free, they would lose revenue. Nowhere in the world has that happened. The revenue, including in Hong Kong and California, where they have introduced smoke-free policies, has gone up and not down.

Another fallacy is the government would lose money if it puts up the tax.

This does not happen. Some smokers will still pay more for cigarettes, so the revenue goes up. The number of smokers will come down particularly among the young and the poor.

There are so many economic fallacies that some non-governmental organisations propagate. Sometimes, governments almost innocently believe these economic arguments.

Q: If the situation is so dire, why can’t countries impose a blanket ban on cigarettes?

A: No country has put a blanket ban on cigarettes. Authorities have learnt from the prohibition of alcohol in the United States (1920-1933), for example, that it leads to much bigger implications particularly with crime and corruption cases.

So, the idea is to slowly push tobacco use back, so that the reduction is genuine and it is done throughout the community. This is what every government is really trying to do rather than actually ban it.

Q: Malaysia aims to be smoke-free (the End Game of Tobacco) by 2045. Are we moving in the right direction?

A: I strongly commend Malaysia for the foresight in establishing the 2045 goal and targets; few countries have yet to do this.

Recently the prevalence of male smokers has begun to decrease.

It is going to require a major commitment by the government and a huge effort by academia as well as non-governmental organisations in achieving this goal.

The Health Ministry has worked out a year-by-year plan of reducing prevalence up to 2045. It has developed a roadmap and has filled in what needs to be done each year to achieve the goal.

But it is not a quick process: if a country reduces its prevalence by one per cent a year, it is doing quite well.

So, it’s possible for Malaysia, but it will be challenging.

Study: China Struggles to Kick World-Leading Cigarette Habit

Most smokers in China, the world’s largest tobacco consumer, have no intention of kicking the habit and remain unaware of some of its most damaging health effects, Chinese health officials and outside researchers said Wednesday.

http://www.voanews.com/a/china-smoking/3879050.html

An estimated 316 million people smoke in China, almost a quarter of the population, and concerns are growing about the long-term effects on public health and the economy.

The vast majority of smokers are men, of whom 59 percent told surveyors that they have no plans to quit, according to a decade-long study by the Chinese Center for Disease Control and Prevention and Canadian researchers with the International Tobacco Control project.

Such numbers have prompted efforts to restrict the formerly ubiquitous practice. Major cities including Beijing and Shanghai having recently moved to ban public smoking, with Shanghai’s prohibition going into effect in March. In 2015, the central government approved a modest nationwide cigarette tax increase.

But Chinese and international health officials argue that more is needed, including a nationwide public smoking ban, higher cigarette taxes and more aggressive health warnings. Such actions are “critically important,” Yuan Jiang, director of tobacco control for the Chinese Center for Disease Control, said in a statement released with Wednesday’s study.

A public smoking ban appeared imminent last year. The government health ministry said in December that it would happen by the end of 2016, but that has yet to materialize.

“They have to figure out what’s important as a health policy,” said Geoffrey Fong of Canada’s University of Waterloo, one of the authors of Wednesday’s study. “Every third man that you pass on the street in China will die of cigarettes. …When you have cheap cigarettes, people will smoke them.”

In line with global trends, smoking rates among Chinese have fallen slowly over the past 25 years, by about 1 percent annually among men and 2.6 percent among women, according to a separate study published in April in the medical journal The Lancet.

Yet because of China’s population growth — 1.37 billion people at last count — the actual number of smokers has continued to increase. Rising prosperity means cigarettes have become more affordable, while low taxes keep the cost of some brands at less than $1 a pack.

Sixty percent of Chinese smokers were unaware that cigarettes can lead to strokes and almost 40 percent weren’t aware that smoking causes heart disease, according to the study, which was released on World No Tobacco Day, when the World Health Organization and others highlight health risks associated with tobacco use.

Judith Mackay, an anti-tobacco advocate based in Hong Kong, said China has made strides with the public smoking bans in some cities and a similar ban covering schools and universities, but that’s not enough.

“This is the first time there has been a report looking at the overall picture of where China stands,” said Mackay, senior adviser at Vital Strategies, a global health organization. “The reality is, it’s falling behind.”

Mackay blamed behind the scenes lobbying by China’s state-owned tobacco monopoly for impeding efforts to toughen tobacco policies. The State Tobacco Monopoly Administration did not immediately respond to a request for comment.

Government agencies and research institutes in China, Canada and the United States funded the study.

World No Tobacco Day 2017

World No Tobacco Day 2017: Beating tobacco for health, prosperity, the environment and national development

http://www.who.int/mediacentre/news/releases/2017/no-tobacco-day/en/

Action to stamp out tobacco use can help countries prevent millions of people falling ill and dying from tobacco-related disease, combat poverty and, according to a first-ever WHO report, reduce large-scale environmental degradation.

On World No Tobacco Day 2017, WHO is highlighting how tobacco threatens the development of nations worldwide, and is calling on governments to implement strong tobacco control measures. These include banning marketing and advertising of tobacco, promoting plain packaging of tobacco products, raising excise taxes, and making indoor public places and workplaces smoke-free.

Tobacco’s health and economic costs

Tobacco use kills more than 7 million people every year and costs households and governments over US$ 1.4 trillion through healthcare expenditure and lost productivity.

“Tobacco threatens us all,” says WHO Director-General Dr Margaret Chan. “Tobacco exacerbates poverty, reduces economic productivity, contributes to poor household food choices, and pollutes indoor air.”

Dr Chan adds: “But by taking robust tobacco control measures, governments can safeguard their countries’ futures by protecting tobacco users and non-users from these deadly products, generating revenues to fund health and other social services, and saving their environments from the ravages tobacco causes.”

All countries have committed to the 2030 Agenda for Sustainable Development, which aims to strengthen universal peace and eradicate poverty. Key elements of this agenda include implementing the WHO Framework Convention on Tobacco Control, and by 2030 reducing by one third premature death from noncommunicable diseases (NCDs), including heart and lung diseases, cancer, and diabetes, for which tobacco use is a key risk factor.

Tobacco scars the environment

The first-ever WHO report, Tobacco and its environmental impact: an overview, also shows the impact of this product on nature, including:

  • Tobacco waste contains over 7000 toxic chemicals that poison the environment, including human carcinogens.
  • Tobacco smoke emissions contribute thousands of tons of human carcinogens, toxicants, and greenhouse gases to the environment. And tobacco waste is the largest type of litter by count globally.
  • Up to 10 billion of the 15 billion cigarettes sold daily are disposed in the environment.
  • Cigarette butts account for 30–40% of all items collected in coastal and urban clean-ups.

Tobacco threatens women, children, and livelihoods

Tobacco threatens all people, and national and regional development, in many ways, including:

  • Poverty: Around 860 million adult smokers live in low- and middle-income countries. Many studies have shown that in the poorest households, spending on tobacco products often represents more than 10% of total household expenditure – meaning less money for food, education and healthcare.
  • Children and education: Tobacco farming stops children attending school. 10%–14% of children from tobacco-growing families miss class because of working in tobacco fields.
  • Women: 60%–70% of tobacco farm workers are women, putting them in close contact with often hazardous chemicals.
  • Health: Tobacco contributes to 16% of all noncommunicable diseases (NCDs) deaths.

Taxation: a powerful tobacco control tool

“Many governments are taking action against tobacco, from banning advertising and marketing, to introducing plain packaging for tobacco products, and smoke-free work and public places,” says Dr Oleg Chestnov, WHO’s Assistant Director-General for NCDs and Mental Health. “But one of the least used, but most effective, tobacco control measures to help countries address development needs is through increasing tobacco tax and prices.”

Governments collect nearly US$ 270 billion in tobacco excise tax revenues each year, but this could increase by over 50%, generating an additional US$ 141 billion, simply from raising taxes on cigarettes by just US$ 0.80 per pack (equivalent to one international dollar) in all countries. Increased tobacco taxation revenues will strengthen domestic resource mobilization, creating the fiscal space needed for countries to meet development priorities under the 2030 Agenda.

“Tobacco is a major barrier to development globally;” says Dr Douglas Bettcher, Director of WHO’s Department for the Prevention on NCDs. “Tobacco-related death and illness are drivers of poverty, leaving households without breadwinners, diverting limited household resources to purchase tobacco products rather than food and school materials, and forcing many people to pay for medical expenses.”

“But action to control it will provide countries with a powerful tool to protect their citizens and futures,” Dr Bettcher adds.

Editor’s note

Tobacco-related illness is one of the biggest public health threats the world faces, killing more than 7 million people a year. But tobacco use is one of the largest preventable causes of noncommunicable diseases.

Tobacco control represents a powerful tool in improving health in communities and in achieving the Sustainable Development Goals (SDGs). SDG target 3.4 is to reduce premature deaths from NCDs by one third by 2030, including cardiovascular and chronic respiratory diseases, cancers, and diabetes.

Another SDG target, 3.a, calls for implementation of the WHO Framework Convention for Tobacco Control (WHO FCTC). The WHO FCTC entered into force in 2005, and its Parties are obliged to take a number of steps to reduce demand and supply for tobacco products. Actions addressed in the Convention include protecting people from exposure to tobacco smoke; banning tobacco advertising, promotion and sponsorship; banning sales to minors; requiring health warnings on tobacco packaging; promoting tobacco cessation; increasing tobacco taxes; and creating a national coordinating mechanism for tobacco control. There are 180 Parties to the Convention.

For more information, please contact:

Paul Garwood
WHO Department of Communications
Telephone: +41 22 791 15 78
Mobile: +41 79 603 72 94
Email: garwoodp@who.int

Christian Lindmeier
WHO Department of Communications
Telephone: +41 22 791 1948
Mobile: +41 79 500 6552
Email: lindmeierch@who.int

Tobacco kills 7 million a year, wreaks environmental havoc: WHO

Smoking and other tobacco use kills more than seven million people each year, the World Health Organization said Tuesday, also warning of the dire environmental impact of tobacco production, distribution and waste.

http://www.timeslive.co.za/world/2017/05/30/Tobacco-kills-7-million-a-year-wreaks-environmental-havoc-WHO

The UN agency said tougher measures were needed to rein in tobacco use, urging countries to ban smoking in the workplace and indoor public spaces, outlaw marketing of tobacco products and hike cigarette prices.

“Tobacco threatens us all,” WHO chief Margaret Chan said in a statement.

“Tobacco exacerbates poverty, reduces economic productivity, contributes to poor household food choices, and pollutes indoor air,” she said.

In a report released ahead of World No Tobacco Day on Wednesday, WHO warned that the annual death toll of seven million people had jumped from four million at the turn of the century, making tobacco the world’s single biggest cause of preventable death.

And the death toll is expected to keep rising, with WHO bracing for more than one billion deaths this century.

“By 2030, more than 80 percent of the deaths will occur in developing countries, which have been increasingly targeted by tobacco companies seeking new markets to circumvent tightening regulation in developed nations.”

Tobacco use also brings an economic cost: WHO estimates that it drains more than $1.4 trillion (1.3 trillion euros) from households and governments each year in healthcare expenditures and lost productivity, or nearly two percent of the global gross domestic product.

In addition to the health and economic costs linked to smoking, the WHO report for the first time delved into the environmental impact of everything from tobacco production to the cigarette butts and other waste produced by smokers.

“From start to finish, the tobacco life cycle is an overwhelmingly polluting and damaging process,” WHO Assistant Director-General Oleg Chestnov said in the report.

The report detailed how growing tobacco often requires large quantities of fertilisers and pesticides, and it warned that tobacco farming had become the main cause of deforestation in several countries.

This is largely due to the amount of wood needed for curing tobacco, with WHO estimating that one tree is needed for every 300 cigarettes produced.

WHO also highlighted the pollution generated during the production, transport and distribution of tobacco products.

The report estimates that the industry emits nearly four million tonnes of carbon dioxide equivalent annually — the same as around three million transatlantic flights.

And waste from the process contains over 7,000 toxic chemicals that poison the environment, including human carcinogens, WHO said.

Once in the hands of the consumer, tobacco smoke emissions spewed thousands of tonnes of human carcinogens, toxic substances and greenhouse gases into the environment.

Cigarette butts and other tobacco waste make up the largest number of individual pieces of litter in the world, the agency said.

Two thirds of the 15 billion cigarettes sold each day are thrown on to the street or elsewhere in the environment, it said, adding that butts account for up to 40 percent of all items collected in coastal and urban clean-ups.

WHO urged governments to take strong measures to rein in tobacco use.

“One of the least used, but most effective tobacco control measures… is through increasing tobacco tax and prices,” Chestnov said.

When Public Health and Big Tobacco Align

Nobody trusts the tobacco industry, and it’s easy to understand why. For decades, industry executives knew that smoking caused cancer and heart disease yet publicly denied the dangers of cigarettes. It relentlessly attacked its critics. Documents that emerged in the 1990s showed that the industry targeted teenagers, knowing that the earlier someone became addicted to cigarettes, the more likely they would be lifelong smokers. And so on.

https://www.bloomberg.com/view/articles/2017-03-09/when-public-health-and-big-tobacco-align

In the 1980s and 1990s, the public health community went to war with the tobacco industry. Though the war largely ended in 1998 with Big Tobacco agreeing to a multi-billion-dollar settlement with the states, it remains a powerful memory for public health.

To this day, most tobacco-control advocates view the cigarette companies as being every bit as duplicitous and evil as they were in the bad old days. Some years ago, I asked Stanton Glantz, perhaps the leading anti-tobacco scientist in the U.S., what his ultimate goal was. He didn’t say it was to eliminate the scourge of smoking. He said: “To destroy the tobacco industry.”

What brings this to mind is an excellent cover story in the upcoming issue of Bloomberg Businessweek about the efforts of the tobacco industry to devise and market so-called reduced risk products like electronic cigarettes — products that give users their nicotine fix without most of the attendant carcinogens that come with combustible tobacco.

Although the tobacco companies have done decades of R&D on smokeless products, the business was dominated early on by startups like NJOY, which is today the largest independent e-cigarette company in America. From the start NJOY has said that a big part of its mission was “to end smoking-related death and disease.” And from the start, messages like that have been scorned by the public health community.

Ingesting nicotine in some smokeless fashion is vastly safer than smoking a combustible cigarette. (In the words of the late South African tobacco scientist Michael Russell, “People smoke for the nicotine but die from the tar.”) Last year, the Royal College of Medicine issued a report saying that e-cigarettes were some 95 percent safer than cigarettes.

Even so, the public health community in the U.S., led by the Centers for Disease Control and Prevention, has done everything it can to demonize smokeless products. Some of this has been with good reason: to try to keep kids from picking up an addictive habit. But this effort has also helped to create the impression that smokeless products are as dangerous as cigarettes. One result, sadly, is that many long time smokers have refused to try them, even though they could save their lives.

My sense in talking to tobacco-control officials over the years is that too many of them simply don’t believe in a reduced-harm approach. We give heroin addicts methadone not because methadone is good but because it is better than heroin. With cigarettes, however, the public health mindset appears to be all or nothing — that the only “right” thing for smokers to do is to go cold turkey.

But the lingering distrust of the tobacco industry has also had a lot to do with public health’s unwillingness to acknowledge the potential benefits of alternative products. Matt Myers, the president of the Campaign for Tobacco Free Kids, has often complained, for instance, about the marketing of e-cigarettes, saying that companies are using the same tactics to hook teenagers that Big Tobacco once used.

With the e-cigarette market clearly established, the four big tobacco companies — BAT, Reynolds American, Altria (formerly Philip Morris) and Philip Morris International (spun off from Altria) — have proclaimed themselves all in.

Philip Morris International is an especially interesting case: Not only does it have an array of e-cigarettes and other smokeless products, but as the Bloomberg Businessweek story points out, it has publicly proclaimed that its goal is to lead the world into “a smoke-free future.” The home page of its website asks, “How long will the world’s leading cigarette company be in the cigarette business?”

As astonishing as it is that a company with $26 billion in tobacco revenue last year would be calling for the end of cigarettes, I believe Philip Morris is sincere. It has spent around $3 billion in research. Its new flagship product, called IQOS, heats tobacco but doesn’t burn it — which the company believes will be more satisfying to smokers than vaping. IQOS already has 7 percent of the tobacco market in Japan, and is being rolled out in other countries.

Philip Morris recently asked the British government that tobacco products “be taxed according to their risk profile.” In other words, it wants the government to impose higher taxes on cigarettes to encourage smokers to move to reduced-risk products. What tobacco company has ever done that before?

In the U.S., Philip Morris has done something extraordinary: It has made a submission to the Food and Drug Administration to get the right to market IQOS as a reduced risk product. The expensive submission consumed 2.3 million pages and is backed by a great deal of research, including several clinical trials. So far, none of the U.S. e-cigarette companies have attempted to get such a designation, and it is a big problem. How do you sell a reduced risk product when you can’t tell anybody it reduces risk?

The business case for diving into this market is that it’s a product category that’s growing, while the cigarette market is shrinking. Philip Morris doesn’t want to be left behind. But there is no particular need for the company to set out such a transformative agenda, at least not yet. The small smokeless companies are not much of a threat. NJOY filed for bankruptcy last fall. And under a 2009 law, every company in the e-cigarette industry will have to file something called a premarket tobacco application with the FDA by August 2018. The submissions will cost, on average, over $450,000, and the companies will have to show that their products have some public health benefit. There is a legitimate chance that some small companies won’t be able to clear the hurdle.

No, Philip Morris is pushing as hard as it is, I believe, because it wants to get on the right side of the issue, finally — to be viewed as a good corporate citizen. When I spoke to Glantz the other day about the company’s new anti-smoking agenda, he said, “I don’t believe them.” (He added, “If they were serious, they would stop marketing cigarettes right now.”)

No doubt many others in the tobacco-control community feel the same way. They still loathe Big Tobacco, and view Philip Morris’s new strategy as just another deception. But the truth is, if there is ever going to be a serious move from cigarettes to less dangerous products, it will have to come from Big Tobacco. They have the R&D resources, they have the marketing apparatus — and, it appears, they have the will.

Public-health advocates don’t have to trust Philip Morris, or any other tobacco company. They don’t have to believe what I believe in order to arrive at the same conclusion: that the advocates should be rooting for the companies’ innovations — pushing them, double-checking their data, making sure regulations are in place to prevent their products from being marketed to kids. The advocates should also be spreading the word that there is an alternative to cigarettes. Who really cares whether it’s Big Tobacco or some other entity that reduces smoking deaths? What matters is that it happens.

The tobacco wars are long over. Continuing to fight the cigarette companies may bring a certain satisfaction to the veterans on the public-health side. But joining forces is the way to save lives.

This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

To contact the author of this story:
Joe Nocera at jnocera3@bloomberg.net

To contact the editor responsible for this story:
Philip Gray at philipgray@bloomberg.net

Who Still Smokes? Designing the Tobacco Endgame

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Addressing the tobacco industry vector

The tobacco industry’s escalating attacks on public health are replicated across the world, as is the harm caused by its products.

http://www.jpost.com/Opinion/Addressing-the-tobacco-industry-vector-482330

‘THE TOBACCO industry attempts to impede tobacco regulation have changed over the years, but have not abated – they have instead mutated, and on a global scale.’

I was privileged recently to deliver the keynote address to the annual meeting of the Israel Society for Smoking Cessation and Prevention. The title was “Advocacy efforts in countering tobacco industry tactics.”

In the address I quoted Dr. Margaret Chan, director- general of the World Health Organization, who in 2008 said, “I want to remind governments in every country of the range and force of counter-tactics used by the tobacco industry – an industry that has much money and no qualms about using it in the most devious ways imaginable.”

Just as the primary vector for malaria is the mosquito, the primary vector for the tobacco epidemic is the tobacco industry. The industry attempts to impede tobacco regulation have changed over the years, but have not abated – they have instead mutated, and on a global scale.

When the WHO’s first and only internationally binding treaty – the Framework Convention on Tobacco Control (WHO FCTC) – entered into force (Israel became a signatory in 2005), there was a dramatic increase in the number of countries implementing tobacco control policies. The industry determined to adapt to the new situation.

According to WHO, the tobacco industry has continued to use advertising, promotion and sponsorship to undermine tobacco control efforts. In addition, it has sought to interfere with tobacco control on a global scale using a variety of tactics. For example, it lobbies and funds politicians and political parties to hijack the political and legislative process. It exaggerates the economic importance of the industry, while remaining silent on the massive health and economic costs of tobacco use. It manipulates public opinion to gain the appearance of respectability, often under the guise of corporate social responsibility, while irresponsibly playing down or denying the real harms its products.

It fabricates support by developing and resourcing front groups who advocate on the industry’s behalf. It continues to attempt to discredit proven scientific and economic evidence – often erroneously claiming that evidence from one country isn’t applicable in another.

And, increasingly, it intimidates governments with litigation or the threat of litigation, or trade threats.

Tobacco companies have recently launched a spate of international legal challenges to oppose the implementation of legitimate and robust tobacco control measures. Bilateral investment treaties have been used as the premise for international commercial arbitration challenges against Uruguay and Australia. This typifies the tobacco industry’s response to countries exercising their regulatory autonomy in the tobacco space: one of untenable intimidation.

This intimidation of governments is important because only governments can ratify and implement UN treaties, such as the WHO FCTC, mandate public health legislation and implement taxation policies that increase the price and reduce the affordability of tobacco products – the single most effective way of reducing tobacco use.

Legal and trade challenges typically have a delaying effect upon the country concerned – the implementation of tobacco control measures is paused until the case is resolved, they are expensive for governments (typically costing millions of US dollars) and have a regulatory chill effect on other countries that might be contemplating similar measures. However, these challenges have been repeatedly dismissed by high courts, constitutional courts and courts of justice in jurisdictions including Australia, the UK, Kenya, France, the European Union, South Africa, Thailand and Uruguay.

In addition, more and more countries are dismissing tobacco industry opposition, and introducing plain packaging. Responding to the industry’s increased use of trade law, Bloomberg Philanthropies and the Gates Foundation announced an $ 4 million fund to support countries against such threats – but we need to adopt other strategies too.

For example, research is often directed toward establishing the rates of smoking prevalence, health and mortality, and the economic impact of tobacco. This research is invaluable, but more effort also should be directed at tracking tobacco industry behavior so we can more efficiently monitor and resist the tobacco industry vector. Many advocates do not even know whether the tobacco industry donates to front groups or politicians in their country; whether the International Tax and Investment Center (funded by the tobacco industry) has visited their Finance Ministry with the mantra of not raising tobacco taxes; or whether the industry has met with government (and under WHO FCTC Article 5.3, the tobacco industry should have no part in formulating tobacco control policy).

This is perhaps why recent allegations regarding tobacco industry bribes to the Israeli government came as such a shock.

The tobacco industry’s escalating attacks on public health are replicated across the world, as is the harm caused by its products. The global tobacco epidemic, which will kill six million people this year, cannot be addressed unless we are equipped to counter all the industry’s tactics and all governments – including Israel’s – stand firm in stopping the tobacco industry from influencing health policy development and implementation.

The current prevalence of smoking in Israel is about 20%. Israel’s next step could be, as many countries have already done, to announce a target of 5% prevalence rate by 2028, and work annually to achieve this target. This is an ambitious target, but challenging rather than impossible.

Designing the Tobacco End Game

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Hong Kong Department of Health Tobacco Control Zero Efforts

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Vapers beware: 10 things to know about e-cigarettes

With catchy names like Smurf Cake and Unicorn Puke and sweet flavors like bubble gum and strawberry, electronic cigarettes may have special appeal to young people, but that doesn’t mean they are safe.

https://www.universityofcalifornia.edu/news/vapers-beware-ten-things-know-about-e-cigarettes

Evidence is mounting that e-cigarettes are exposing a new generation to nicotine addiction and may be leading users toward a cigarette habit. As a result, the U.S. surgeon general last month issued a report declaring youth e-cigarette use “a major public health concern.”

“All Americans need to know that e-cigarettes are dangerous to youth and young adults,” said Surgeon General Vivek Murthy, in releasing the report. “Any tobacco use, including e-cigarettes, is a health threat, particularly to young people.”

The battery-powered devices heat a liquid typically containing nicotine mixed with the chemicals propylene glycol and glycerin as well as flavorings to deliver an aerosol inhaled by the user. While e-cigarettes deliver nicotine without the tar and smoke of traditional tobacco cigarettes, they still are considered tobacco products.

But their healthy halo has helped propel their popularity: E-cigarettes are now so popular that more American youth vape than smoke cigarettes. In just a decade, e-cigarettes have become a multibillion-dollar business led by multinational tobacco companies with outlets not just online but everywhere from vape shops to convenience stores and retail giants like Wal-Mart.

Ads tout them as a cool, harmless alternative to cigarettes. E-cigarette users, or vapers, have contests to see who can blow the largest cloud of vapor.

But there’s more to e-cigarettes than meets the eye. The surgeon general’s report aligns with increasing scrutiny of e-cigarettes, from new regulations to a growing body of research into health effects.

Here are 10 things to know about e-cigarettes:

E-cigarettes contain nicotine

E-cigarettes contain nicotine, which is addictive and can harm the developing adolescent brain, said UC San Francisco professor of medicine Stanton Glantz.

A lot of the kids who take up vaping are at low risk for smoking, but once they start using e-cigarettes, they are three to four times more likely to start using cigarettes, Glantz said.

“The biggest health concern with e-cigarettes is they are prolonging and expanding the tobacco industry,” Glantz said.

Glantz, director of UCSF’s Center for Tobacco Control Research and Education, said he was initially neutral on e-cigarettes, but now finds them concerning. Among other hazards, e-cigarettes produce ultrafine particles than can trigger inflammatory problems and lead to heart and lung disease.

“The data is just becoming overwhelming,” Glantz said.

E-cigarettes expose people to more than ‘harmless water vapor’

E-cigarettes are billed as producing “harmless water vapor,” but, strictly speaking, the vapor produced when users exhale is actually an aerosol that contains a mixture of nicotine, flavorings and other ingredients that can be toxic.

Stanford University pediatrics professor Bonnie Halpern-Felsher has studied young people’s perceptions of e-cigarettes. In September, she launched a free, downloadable youth tobacco prevention toolkit with an e-cigarette module, funded by the UC Tobacco-Related Disease Research Program (TRDRP) and the California Department of Education.

“Youth are definitely using e-cigarettes because they think they are cool,” Halpern-Felsher said. “Adolescents and young adults don’t know a lot about e-cigarettes. They think it’s just water or water vapor. They don’t understand it’s an aerosol. They don’t understand that e-cigarettes can have nicotine. They don’t understand that flavorants themselves can be harmful.”

The flavors can be toxic

More than 7,000 varieties of flavored e-cigarettes are on the market.

UC Riverside professor of cell biology Prue Talbot screened the cytotoxicity (quality of being toxic to cells) of 36 refill fluids and found that some were highly toxic. The most cytotoxic flavor, Cinnamon Ceylon, contained a chemical called cinnamaldehyde, which gives cinnamon its flavor and whose side effects may include coughing and sore throats. Talbot has been studying more flavors and is building a database to help determine the most dangerous ones.

“Flavors are something that could be potentially regulated,” Talbot said.

Vaping has secondhand and thirdhand effects

Unlike cigarettes, which emit smoke from the lit end, e-cigarettes don’t produce sidestream emissions between puffs, but they still generate secondhand and thirdhand effects when users exhale the mainstream vapor.

In a TRDRP-funded study, Berkeley Lab researcher Hugo Destaillats led a team that found 31 chemicals that include several toxicants at significant levels in e-cigarette vapor. The most toxic chemicals included acrolein, a severe eye and respiratory irritant; and formaldehyde, an irritant and probable carcinogen.

Emissions varied by type of device and voltage.

“The way you heat the liquid drastically determines if you produce a lot of compounds or just a few,” Destaillats said. “As you increase the voltage, toxic byproduct concentrations increase exponentially.”

The batteries can explode

There were 134 reports of e-cigarette batteries overheating, catching fire or exploding between 2009 and January 2016, according to the Food and Drug Administration, which will host a public workshop in April to gather information about e-cigarette battery safety concerns.

E-cigarette batteries “can explode without notice,” Talbot said. “People can be quite severely injured.”

E-liquids are poisonous if swallowed

Calls to poison control centers about e-cigarette exposure in young children have skyrocketed nationally in recent years. In California, the number of calls involving e-cigarettes increased from 19 in 2012 to 243 in 2014, according to the UC-administered California Poison Control System. More than 60 percent of those e-cigarette calls were related to nicotine poisoning in children 5 and under.

E-cigarettes show mixed results in helping smokers quit

While some people have quit smoking with e-cigarettes, on average, adult smokers who use e-cigarettes are about 30 percent less likely to stop smoking cigarettes, Glantz said. Also, e-cigarettes are associated with more, not less, cigarette smoking among adolescents.

“If you are a middle-aged person who has been smoking for 20 years, maybe it is good to switch to e-cigarettes,” Destaillats said. “But if you are a teenager and never have smoked, then it is not a good idea to use e-cigarettes.”

The minimum age has risen

In June, California became the nation’s second state, following Hawaii, to raise the minimum age for tobacco sales to 21, and for the first time added e-cigarettes to the definition of tobacco products. In August, the FDA extended its tobacco oversight to e-cigarettes, banning sales to those under 18.

“It sends a message to youth that e-cigarettes are in the same category of all tobacco products,” Halpern-Felsher said.

E-cigarettes will be taxed

Under Proposition 56, the tobacco tax passed by California voters in November, the state will tax e-cigarettes for the first time, starting April 1. It’s estimated that the price of a typical 30-milliliter bottle of e-liquid could increase to about $30 from $20.

“Anytime you increase the price, people buy less,” Glantz said.

The tax revenue will enhance education efforts by boosting funding for the state Tobacco Control Program. The surgeon general’s report also will make it easier for states to integrate e-cigarettes into tobacco education campaigns and could lead to more regulations, Glantz said.

E-cigarettes may be safer than cigarettes, but unknown risks remain

Expect more information to emerge about e-cigarettes as studies examine long-term effects.

“It’s often assumed that e-cigarettes are safer than cigarettes, but that could be an incorrect assumption,” Talbot said. “We don’t yet know the long-term health effects of e-cigarettes.”

Decades of research have helped scientists determine that cigarette smoke creates more than 7,000 chemicals, at least 69 of which are known to cause cancer and many of which are poisonous.

So, while e-cigarettes deliver fewer cancer-causing chemicals than cigarettes, research has yet to reveal how e-cigarettes fully impact heart and lung health and their cancer-causing potential, Glantz said.

He estimates that e-cigarettes are about one-third to one-half as dangerous as cigarettes.

In other words, they are still plenty dangerous.

“Regular cigarettes are super unhealthy,” Destaillats said. “E-cigarettes are just unhealthy.”