Dr Judith Mackay
The tobacco industry’s escalating attacks on public health are replicated across the world, as is the harm caused by its products.
‘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.
COSH urges the Government to take full account of public opinions Enact Enlargement of Pictorial Health Warnings Promptly
Hong Kong Council on Smoking and Health (“COSH”) urges the Government and Legislative Council to enact the enlargement of pictorial health warnings promptly in order to reduce the attractiveness of tobacco, motivate more smokers to quit and deter youth from trying the first cigarette. Mr Antonio KWONG, COSH Chairman remarked, “Results from survey conducted by COSH and two rounds of public consultations organized by the Legislative Council showed that majority of citizens and organizations supported the enlargement of pictorial health warnings to 85%. The Government and Legislative Council should take full account of public opinions and enact the proposed tobacco control measure as soon as possible.”
The Government briefed the legislative proposals to strengthen tobacco control on 18 May 2015, including enlarging the size of pictorial health warnings to at least 85% of the two largest surfaces of the packet, increasing the number of forms of health warning from six to twelve and adding the quitline 1833 183. The date of enactment is yet to be scheduled after more than one and a half years.
The Legislative Council collected views of the public and held special meetings on the enlargement of pictorial health warnings twice. Among the hundred submissions received in July 2015 regarding the increase in the size of pictorial health warnings, more than 80% supported. Besides, over 100 submissions were received for the special meeting of Legislative Council Panel on Health Services to be held tomorrow (17 January 2017), in which around 70% agreed the proposed measure.
The School of Public Health of The University of Hong Kong was commissioned by COSH to carry out the Tobacco Control Policy-related Survey 2016. It was found that public support on enhancing the pictorial health warnings was overwhelming, 79.5% of all respondents agreed to display more threatening messages about the health risks of smoking. About 72.5% of all respondents supported to increase the coverage of the health warnings to 85% while about half of the current smokers also supported. Majority of respondents opted for plain packaging* of cigarettes as well. In addition, COSH has collected over 26,500 signatures from citizens and organizations through street counters and online platform supporting the enlargement of pictorial health warnings since May 2015.
In recent years, many countries have successfully introduced more stringent measures to regulate tobacco packaging. Prof Judith MACKAY, Director of Asian Consultancy on Tobacco Control and Senior Policy Advisor of World Health Organization claimed, “Hong Kong ranked the 72nd in the world regarding the implementation of pictorial health warning and behind many developing countries like Laos, Myanmar and Sri Lanka. Hong Kong should enlarge and strengthen the pictorial warnings promptly in order to reduce the use of tobacco.” World Health Organization called for more countries to enlarge pictorial warnings covering more than 85% and implement plain packaging. “Get ready for plain packaging” was designated as the theme of World No Tobacco Day 2016.
Recently, some organizations opposed the proposed enlargement of warnings in the pretext that it would lead to a surge in cigarette smuggling activities. A recent study also claimed that illicit cigarettes composed for around 30% of cigarette consumption in Hong Kong. Prof LAM Tai-hing, Chair Professor of Community Medicine cum Sir Robert Kotewall Professor in Public Health, School of Public Health, The University of Hong Kong said, “the public should express reservation on the results of this tobacco industry-funded study. The data collection methods and calculations of the study were unclear using dubious methods.” The tobacco industry and its allies always express strong opposition against tobacco control measures proposed by the Government under the pretext that it will lead to a surge in cigarette smuggling activities. As recommended by the World Health Organization, the most effective measure against smuggling is tight control and aggressive enforcement.
With the Government’s multi-pronged tobacco control policies over the years, the smoking prevalence in Hong Kong has gradually reduced from 23% in early 80s to 10.5% in 2015. In view of the tobacco epidemic in Hong Kong and the international tobacco control trend, we urge the Government and Legislative Councilors to take account of public opinions and implement the enlargement of pictorial health warnings as soon as possible to safeguard public health. The Government should also actively consider adopting plain packaging within 2 to 3 years and develop long-term and comprehensive tobacco control policies including regulating the emerging tobacco products and e-cigarettes, raising tobacco tax substantially, expanding no-smoking areas, increasing resources on education, publicity, smoking cessation services and enforcement to further reduce the smoking prevalence in Hong Kong and protect people from the harms of smoking and secondhand smoke.
*Remarks: Plain packaging standardizes and simplifies the packaging of tobacco products. The pictorial health warnings on the main sides of cigarette pack are expanded. All forms of tobacco branding should be labeled according to the government prescriptions and with simple and plain format. This means that trademarks, graphics and logos are not allowed on cigarette packs, except for the brand name that is displayed in a standard font size, colour and location on the package. The packaging should not contain other colours and should include only the content and consumer information, such as toxic constituents and health warnings required by law. The quitline number should also be displayed at a prominent position. Australia was the first country to introduce plain packaging in 2012. The measure was also implemented in the United Kingdom, France and Hungary in 2016 and will be implemented in Ireland in 2017.
Survey finds most in favour of move, which advocates say can protect public health and encourage more to quit habit
An anti-smoking body has pressed the government to speed up legislation on cigarette pack health warnings after a survey revealed almost 80 per cent of people desired sterner messages on smoking risks.
The Council on Smoking and Health made the call ahead of another public hearing held on Tuesday in the Legislative Council to collect views on whether to implement the law.
The legislation will expand the size of health warnings on cigarette packs from the current 50 per cent to 85 per cent of the packaging surface.
The proposal was first submitted by the government in May 2015, and the first hearing was held in July in the same year.
According to a survey commissioned by the council and done between February and September last year, 79.5 per cent of 2,058 respondents – comprising smokers, non-smokers and ex-smokers – want cigarette packs to show clearer and more graphic warnings.
Another 72.5 per cent of them also want to see the graphic warnings enlarged to cover 85 per cent of the packaging surface, a move also supported by almost half of the smokers in the survey.
“The implementation work has dragged on for one and a half years. This measure can protect public health and help more people quit smoking.
“We hope that Legco will not procrastinate on the legislation any further,” council chairman Antonio Kwong Cho-shing said.
He said that Australia recorded a drop of 2.2 percentage points in average smoking rate after introducing plain cigarette packaging in 2012.
Of this amount, 0.55 percentage points, or 108,000 fewer smokers, were due directly to the new measure which only allowed brand names to be displayed in a standard font size, colour and position on the packaging, thereby making them less conspicuous and seemingly less desirable.
Professor Judith Mackay, a veteran tobacco control advocate and senior policy advisor for the World Health Organisation, said a larger graphic warning would have an even bigger visual impact and induce more smokers to quit.
According to a Canadian Cancer Society survey which studied the effectiveness of health warnings on cigarette packs worldwide, Hong Kong ranked 72nd out of 205 places.
“We used to be among the top 12 jurisdictions [in cigarette pack warnings] … now we are lagging very far behind from the international experience,” Mackay said. She has been working on tobacco control advocacy in the city for more than 30 years.
The survey done by the Canadian group looked at various factors, including whether graphic warnings existed on the packaging design, the sizes of the images and when the warnings were introduced.
Mackay attributed the city’s poor ranking partly to outdated warnings, which were first introduced in 2007, and the lack of information on helpline numbers for those seeking to quit the habit.
She said in the long run the government should also further increase tobacco tax to make cigarettes less affordable.
Kwong from the Council on Smoking and Health said it submitted a letter to the financial secretary late last year to suggest increasing tobacco tax to 100 per cent.
Your editorial (“Preventive health care is an investment, not a burden ”, January 1) has hit the nail on the head regarding the importance of, and investment in, prevention versus cure in Hong Kong.
We all need the “ambulance and curative services” to rescue us when we are taken ill, but unless the whole of government – particularly the finance, trade and economic branches, as well as the Independent Commission Against Corruption and the Ombudsman – grasps the political nettle of issues such as tobacco control, health will never improve, nor will the many thousands of annual deaths from tobacco be reduced.
Indeed, the entire Hong Kong government is under an international obligation to do so, being a party to the World Health Organisation Framework Convention on Tobacco Control.
One of the most important platforms of any incoming chief executive is their future preventive health plan for Hong Kong citizens.
Let us call upon each of the potential chief executive candidates to outline their health platforms. We should discard all those who see these platforms in terms of more hospital beds, which will never solve the problem of improving Hong Kong’s health. And the current health paradigm is such that improvements will only come about by addressing the vested interests of big business – the tobacco, alcohol, food, and even salt industry –including their often unrecognised front groups.
With tobacco control, we have known for decades what works, and how very cost-effective these measures are. Yet governments around the world hesitate to act.
Increasing tobacco tax heads the list of the best single measure to reduce smoking. It may be surprising to many that a fiscal measure is more important than health education in schools or banning sales to youth, for example, but it is the single best action governments can take to reduce consumption among the young.
Why can Hong Kong not follow Australia and New Zealand and commit to an annual tobacco tax increase of, say, 10 per cent per annum to the year 2025?
Any chief executive candidate who would endorse this would get my (hypothetical) vote.
It would give us an orderly and planned route to follow, and avoid the incredible waste of time and energy lobbying annually for tobacco tax increases. And it would have a massive effect in saving young and middle-aged lives, and in what is termed “frailty avoidance” in the elderly.
Dr Judith Mackay, Clear Water Bay
When a person goes to buy a packet of cigarettes in Hong Kong, he or she faces two obstacles. One is the price — Double Happiness at HK$43 and Marlboro at HK$57 — the result of a tobacco tax up to 68 per cent of the price.
The other is the hideous image on the packet of the worst consequences of smoking.
A survey by the Economic Intelligence Unit earlier this year ranked Hong Kong as the eighth most expensive city in the world for a packet of branded cigarettes, at US$7.48.
Top was London with US$14.30, followed by New York with US$13.67 and Singapore with US$9.15.
These two measures, along with the creation of smoke-free areas in public and work places, have been effective in cutting the number of smokers.
According to government figures, the percentage of daily cigarette smokers aged 15 and above in Hong Kong in 2015 was 10.5 percent, down from 10.7 percent in 2012 and 23.3 per cent in the early 1980s.
The mainland, the world’s largest tobacco market with 316 million smokers in 2015, has only recently started to learn the lessons of Hong Kong.
Since 2010, the number of smokers has increased by 15 million and cigarette production risen by 35 per cent.
The health warnings are written, not visual, and appear modestly at the bottom of the packet. They would not frighten any first-time user.
In 2015, China increased the tobacco tax to 40 per cent. Consumption tax from tobacco in 2015 was 536 billion yuan, an increase of 60 billion from a year earlier. The recommendation of the World Health Organisation (WHO) is that the tax should be 70 per cent of the retail price.
“There is certainly room for future tobacco tax increase,” said Jian Shi, director of the information office of the Taxation Research Institute at the State Administration of Taxation in Beijing.
“In some western countries, the tobacco tax rate has reached 70-80 per cent. The room for the increase needs to be considered based on the development goal of the industry and the condition of national revenue.”
Health professionals argue that increasing the tobacco tax is the quickest and most effective way to cut smoking — by both preventing young people from starting and encouraging smokers to quit.
According to WHO figures, each increase of 10 per cent in the price will cause 3.7 per cent of adults and 9.3 per cent of teenagers to stop smoking.
Antonio Kwong Cho-shing, chairman of the Hong Kong Council on Smoking and Public Health, said that selective or modest hikes would not make much of an impression on smoker numbers in Hong Kong.
“Only a 100 per cent increase in tobacco tax would induce people to quit smoking,” he said. If the government accepted this proposal, an average pack would cost HK$119.
The Department of Health has proposed an enlargement of the health warning.
It said on Nov. 23 that the area of the graphic health warning shall be of a size that covers at least 85 percent of the two largest surfaces of the packet or the retail container and that the number of forms of health warning should be increased from six to 12.
The situation in the mainland is years behind. The biggest obstacle is that the State Tobacco Monopoly Administration (STMA), the world’s biggest manufacturer of cigarettes, is also the industry regulator.
This is despite years of lobbying by China’s health professionals, the WHO and the norms practised around the world. They argue that the two must be separate institutions.
According to WHO figures, 1.2 million die each year in China from smoking-related diseases; this number will double by 2025.
Jian Shi put it succinctly. “The major difficulty lies in that the related departments have quite different views on this matter, and it is difficult for them to reach agreement on this matter. That will cause obstruction to policy making and implementation.”
The STMA opposes graphic health warnings and higher taxes because they would hurt its sales and profits. Yet, simply due to global population expansion, there will be more smokers in 2040 than there are today, so it is difficult to believe that this concern is genuine.
The health lobby has had some success, in the modest increase in tobacco tax and restrictions on smoking in indoor public areas and workplaces and some outdoor areas introduced in Beijing in June 2015. Other mainland cities have taken similar measures at different times.
On Dec. 6, the Beijing Commission of Health and Family Planning said that more than 2,700 people had been fined for violating these restrictions, with total fines of 142,500 yuan, as of Nov. 30 this year.
Professor Dr Judith Mackay, based in Hong Kong and Asia’s leading anti-tobacco campaigner, said that the price of cigarettes in China is still extremely low.
“The latest small tobacco tax increase, while laudable, will not have a serious, sustained effect on reducing smoking. It is time to review the whole tobacco tax structure in China, significantly increase the price of cigarettes and thus protect the health of the Chinese people.
“In Australia, there is a regular increase of 12.5 per cent tobacco excise tax every year. The cost of a packet could soon rise to A$40 (HK$230). Hong Kong and China should both consider long-term tobacco tax planning in this way, so that tobacco control proceeds in an orderly form, and immense energy and time is not wasted year by year in campaigning for a tax increase. Otherwise, thousands will die.”
HER’s is a career involving death threats, secret information passed from shadowy ‘Deep Throat’ figures, being held at gunpoint, and caught up in a trial in which key witnesses were murdered or mysteriously disappeared.
But it might be surprising to learn that these are not the experiences of a spy or globe-trotting investigative journalist, instead they are the experiences of a down-to-earth public health expert from Edinburgh.
Dr Judith Mackay, who studied medicine at Edinburgh University and is a member of the university’s Global Health Academy, has spent years battling the tobacco industry in Asia.
Now, for the first time the Hong Kong-based campaigner has revealed the full extent of the threats she faced in her career, during which she was branded as the most dangerous woman in the world by the international tobacco industry.
She told the Sunday Herald how she was for many years a “lone voice” in working at the forefront of tobacco control, trying raise awareness of the health risks of smoking and advising governments.
“Somebody once asked me do you have to be brave to be a tobacco control advocate today and my answer is no, I don’t think you do,” she said. “But I was the lone voice in the wilderness – I was basically the only person in Asia working on tobacco control regionally.
“The tobacco industry had just assumed it would ride its Marlboro cowboy into Asia and there wouldn’t be any opposition at all.”
Mackay, who was born in Yorkshire, moved to Hong Kong in 1967 at the peak of the Chinese Cultural revolution and spent a number of years working as a hospital doctor.
However she began to feel like the work was a ‘band-aid’ in having to treat so many people who had become ill as a consequence of smoking.
She decided to devote her career to tackling the industry full-time in the mid-1980s after a cigarette company attacked her work.
She said: “It [the company] was making a lot of threatening statements about how I was unaccountable and unrepresentative, claiming the tobacco industry was full of good sensible corporate advice. It was one of the turning points in my life.”
Mackay outlined the experiences she has gone through in a blog written for the ‘Dangerous Woman Project’ , which is being run by Edinburgh University’s Institute of Advanced Studies in the Humanities to collate stories of women who have been labelled as ‘threatening’.
She told how she has suffered verbal abuse over the years and in 1993, a US smokers’ rights group described her as a “psychotic human garbage, a gibbering Satan, an insane psychotic just like Hitler.”
The group also threatened to “utterly destroy” her – which was investigated by the FBI and led to her being offered 24-hour police protection by the Hong Kong government.
Mackay, who is a senior policy advisor for the World Health Organisation and director and founder of the Asian Consultancy on Tobacco Control, also had a chilling experience when she was an expert witness in a major trial involving cigarettes being smuggled into China.
The chief witness was murdered and eleven others disappeared – and Mackay discovered that she was being followed.
She helped the Hong Kong government take action against the importation and sale of smokeless tobacco, such as snuff, after she learned a ‘Deep Throat’ figure associated with the US tobacco industry had blown the whistle on a plan to immediately launch these products in the country.
In 1990, while she was working in Mongolia and staying at a government guest house, she found herself being held at gunpoint by suspicious Mongolian palace guards after going for an evening walk. She also found out there had been a cabinet meeting held to discuss whether she was a spy sent from the west.
But Mackay said her experiences had not deterred her from the fight against tobacco.
She said: “I have said – even to my lawyer – that if I were to disappear or to be found under a bus, this is not of my own doing.
“I think if anything I got very empowered by all these things that happened – it made me more determined, rather than less determined.
“But I did take some practical steps – one of which was to send our two boys when they were teenagers back to Scotland to school.
“I just felt they were safer back in the UK to finish their schooling.”
Mackay, whose husband is from Lossiemouth, still spends three months of the summer every year in Edinburgh.
The recognition for her work includes being named as one of the most influential people in the world by Time magazine in 2007. She was also awarded an honorary degree by Edinburgh University in July this year.
At the age of 73, she practises tai-chi and has no intention of giving up her work.
Mackay said while much progress has been made in tobacco control, she believes she will still be tackling the tobacco industry for years to come.
“The tobacco industry is certainly as formidable as it ever was – it has just somewhat changed its tactics in terms of what it does,” she said.
“What they now do is to issue legal challenges and trade threats to governments.”
She added: “I have often said I am going to be working until I am 100 and I think that is probably true.”