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May, 2009:

When What You See Is What You Get

Shin Young-soo, SCMP – May 30, 2009

I clearly recall the first time I glanced at the image of a diseased mouth on a cigarette pack. The photo showed rotting black teeth and bloodied ulcers on the gums, lips and tongue of a young person. I cringed for a moment but let the feeling subside.

I have been around chronic smokers all my life. Most of them seem immune to reason or to any medical information about the bad effects of tobacco. “I know, I know. It’s bad for my health,” is the usual retort. “But what can I do?” End of conversation.

Recent research, however, shows that smokers do not know exactly what tobacco use does to their bodies. Smoking is primarily associated with lung cancer but, in fact, tobacco kills far more people through heart disease than cancer.

In China, for example, a February survey showed that 37 per cent of smokers knew that smoking caused lung disease, but only 17 per cent knew that it caused strokes. In a 1996 national survey in South Africa, it was reported that 87 per cent of respondents acknowledged the harmful effects of smoking, but only 58 per cent were aware that it was associated with cancer and only 36 per cent associated it with heart disease. Studies in India show that fewer than half of school and college students in Gujarat (a tobacco-growing state) were aware that chewing betel nut with tobacco is linked to oral cancer.

Bridging the gap between what the public health community knows about tobacco and what smokers know has always been a challenge.

For this year’s World No Tobacco Day, tomorrow, the World Health Organisation is focusing on the issue of pictorial health warnings on cigarette packs. Research on the use of these warnings points to a “teaching moment” on the product itself. When what you see on the pictorial health warning is what you may get, it is highly likely that you will think again about pulling out that next cigarette.

In Brazil, for example, more than half of smokers changed their opinion on health consequences after seeing pictorial warnings, and 67 per cent said the warnings made them want to quit. In Singapore, 71 per cent of smokers said that they knew more about the health effects of smoking after the introduction of warnings, and 28 per cent said they consumed fewer cigarettes because of them. In Canada, 27 per cent smoked less inside their homes as a result of the warnings.

Recently, in Brazil and New Zealand, pictorial warnings have been accompanied by quit hotline numbers. In the six months following the implementation of pictorial warnings with a quit hotline reference, calls to the line increased ninefold in Brazil, and by 14 per cent in New Zealand (where more callers said they had got their information about hotlines from packs with pictorial warnings rather than television ads).

Research also shows that the more shocking and unpleasant the photographs, the more likely they are to result in behavioural change. Studies also show that avoidance of these photos by smokers does not decrease their effectiveness in getting them to quit.

Legislation requiring tobacco companies to use pictorial warnings has been opposed by the tobacco industry on the grounds that there is no evidence that these kinds of warnings work or that these warnings violate freedom of speech and trademark rights. But, in fact, the evidence that pictorial warnings work is robust. The tobacco industry lost its only serious court challenge against pictorial warnings before the Supreme Court of Canada in 2007.

Litigation may still be a possibility in some countries, and there are also lessons learned from countries like Thailand, for example, on how to handle threats of litigation. In Thailand, the industry argued that pack warnings violated Thai Constitution Article 29 on individual rights and freedom to speak, write, print and advertise.

In response, the Ministry of Public Health insisted through the media that the state could limit individual rights or freedom to protect national security and the health of consumers and citizens. The secretary general for Human Rights in Thailand publicly supported the position of the Ministry of Public Health. The director of the Thai Health Promotion Institute challenged the industry to sue the government.

Through a series of public announcements from different authorities, the government called the industry’s bluff, and the tobacco control community won the public debate and successfully got the people themselves on their side.

To fulfil obligations to the WHO Framework Convention on Tobacco Control, countries in the WHO Western Pacific Region have three years from entry into force of the convention to implement warnings on tobacco products. Shocking and unpleasant pictorial warnings remain in the mind long after that first glance at a pack. It’s time for governments to use shock tactics.

Dr Shin Young-soo is WHO regional director for the Western Pacific

More Cigarette Photo Warnings Suggested

RTHK – 30 May 2009

The government has been urged to amend the Public Health Ordinance to enable the Health Department to change pictorial health warnings on cigarette packets on a regular basis. This came after a survey of nearly 47-thousand secondary school students showed that less than half of them felt the pictures currently displayed on the packets were effective enough to discourage them from smoking. The poll was conducted by the Committee on Youth Smoking Prevention.

Should The Smoking Ban Be Delayed?

SCMP – May 30, 2009

During the recent debate, in these columns, over the delayed additional restrictions on people smoking in public areas, the key point seems to have been overlooked – that is, it is a proven scientific fact that smoking makes people ill, in many cases very ill indeed. Hundreds of thousands of people die each year as a direct consequence of smoking, or of being obliged to inhale the poisonous fumes emitted by others.

We would all be aghast at the thought of allowing people to inject themselves with heroin, or to snort coke in public places. So why should tobacco control be claimed as being in a different category?

And quite apart from the health dangers to all concerned, non-smokers generally find it unpleasant to take a drink, or a meal, when surrounded by such fumes. The sooner that wider ranging tobacco-control measures are introduced (including the abandonment of duty free allowances for tobacco products), the sooner that the health of smokers and non-smokers alike will be endangered less.

Paul Surtees, Mid-Levels

Should The Smoking Ban Be Delayed?

SCMP – May 29, 2009

P. A. Crush (Talkback, May 22) referring to my letter (Talkback, May 20) states “there is no scientific proof” of my claim “that 3,485 people will have died in Hong Kong during the past 30-month exemption of new smoking controls in bars and other licensed entertainment premises”.

The scientific data is factually based on expert reports in 1999 and 2005 citing 1,324 passive smoking annual deaths. Indeed, the data need updating.

Since Hong Kong people were granted exemptions in qualifying bars and nightclubs for 30 months from January 2007 they managed to consume 38.2 million more cigarettes per month (a total of 458.48 million cigarettes more in 2008) than in pre-ban 2006.

Accordingly, the passive smoking death rates are now certainly higher than before the 1,324 annual figure.

The referenced scientific report is “Mortality associated with passive smoking in Hong Kong” (British Medical Journal) authored by eminent professors from the University of Hong Kong’s department of community medicine and Nuffield department of clinical medicine, at Oxford University, England.

The other report is “Cost of tobacco-related diseases, including passive smoking, in Hong Kong”, again by HKU’s department of community medicine and the Centre of National Research on Disability and Rehabilitation Medicine, at the University of Queensland, Brisbane, Australia.

The data revealed in 1998 that the annual value of direct Hong Kong medical costs, long-term care and productivity loss was US$532 million for active smoking and US$156 million for passive smoking; passive smoking accounted for 23 per cent of the total costs. Adding the value of attributable lives lost brought the annual cost to US$9.4 billion, and 1,324 deaths were attributable to passive smoking. Of the passive smoking-attributable deaths, 239 were from lung cancer, 303 from chronic obstructive pulmonary disease, 309 from ischemic heart disease and 473 from stroke. This amounts to 6,920 tobacco-related deaths out of a total of 32,847 deaths in a population of 6.5 million people in 1998.

As seen from the above expert data, your correspondent misguidedly further states “private cars do far more proven harm to our environment and health than any cigarette smoker”. The main polluters of the atmosphere in Hong Kong are the coal-burning power companies, diesel emissions and emissions from ships that last year resulted in 1,155 premature deaths (Hedley Index).

James Middleton, chairman, anti- tobacco committee, Clear the Air

World’s First Discovery: Second-Hand Smoke Increases Stroke Deaths by 50% in Non-Smokers

Source: – press release on 27 Jan 2005

A new and unique study of the impact of second-hand smoke on the health of non-smokers living with a smoker has shown for the first time that passive smoking is an important cause of death from stroke, in addition to heart and lung diseases and cancers. The work was carried out by the Department of Community Medicine and School of Public Health, Faculty of Medicine, HKU, Department of Health and the University of Oxford.

Please visit for details.

Drivers on Drugs Pose Enforcement Dilemma – Little Data Available on Drug-related Accidents

Anita Lam, SCMP – May 28, 2009

Nearly 15 per cent of the drivers who died in traffic accidents over the past five years had taken drugs, but only two drivers were charged with driving under the influence of drugs during the same period.

Giving these figures yesterday, the government said there was no way at present of knowing exactly how many accidents and resulting casualties were caused by drivers under the influence of drugs other than alcohol.

Secretary for Transport and Housing Eva Cheng said that while drug-driving was an offence, unlike alcohol there was no prescribed limit on the amount of medication for driving nor any rapid drug-screening device to help police ascertain if a driver had taken drugs.

She was replying in the Legislative Council to a question from Liberal Party lawmaker Miriam Lau Kin-yee on why no mechanism was in place to support enforcement of the law.

There were established parameters relating to drink-driving, and breath tests, “but no relevant standards and arrangements are provided in the law on drug-driving offences”, she said.

“Unlike alcohol, it is difficult to ascertain the effect of each type of drug on driving behaviour,” she said. “There are various kinds of drugs ranging from over-the-counter medicine such as painkillers, cough mixture to prohibited dangerous drugs. The safe dosage for different drugs also differs.”

According to autopsy reports provided by the government laboratory, traces of drugs were found in the blood of 35 of the 245 drivers who died in road accidents between 2004 and 2008, of whom 10 had also consumed alcohol. Although most of the drugs detected were pain killers and respiratory medication, 13 had taken drugs including ketamine, morphine and cocaine.

But during that five years only two people had been prosecuted for drug-driving and both were convicted after admitting guilt. One was fined HK$1,000 and disqualified from driving for a year, while the other was prohibited from driving for six months and placed on probation for a year.

Although police can now perform random breath tests on drivers, they can do little even if they suspect any of them are on drugs unless they breach alcohol laws.

The bureau said police could ask drivers if they have taken drugs or search a vehicle if they had reasonable suspicion.

If both moves fail to turn anything up, police could ask for blood or urine tests on drivers.

A government source said Hong Kong could the follow the Australian model where hospitals were allowed to collect blood sample from drivers involved in accidents, not for prosecution but for statistical research so authorities could at least gauge the magnitude of the problem.

Ms Cheng said the government would continue to look into the issue and study overseas jurisdictions but stressed that any amendments in legislation must be balanced with human rights and privacy considerations.


James Middleton, Clear the Air says : Nicotine is a drug. It has the same effect as heroin and cocaine. Why is smoking allowed whilst driving ? Driving with one hand and inhaling a lit addictive drug from the other hand must surely constitute careless driving. If drivers commit an offence by driving whilst using a mobile phone then smoking when driving is far worse. At the same time ,smoking with children in cars should be illegal.

Canadian Expert Panel on Tobacco Smoke and Breast Cancer Risk


‘Extortionists’ Need to Take Cut As Well

SCMP – 27 May 09

Here’s how Hong Kong capitalism works. The capitalists – Public Eye likes to call them extortionists – will charge you profiteering prices for everything from plane tickets and bar drinks to a tin of sardines. Those prices will stay at profiteering levels even when economic times are tough. The capitalists will still hit you with HK$60 drinks and fake supermarket sales. But they’ll go running to the government for relief measures financed with your tax dollars. That’s what the bar owners, retailers and tourism trade are doing right now, marching in the streets to demand government help from the financial crisis and swine flu. They want to delay the smoking ban, waive sewage charges, get cheap government loans, and handouts. Here’s some advice: if you think the smoking ban will break the bars, charge less for your drinks. The customers will pour in. And to the travel trade we say this: afraid of the swine flu? Cut ticket prices. Your planes will be full.

Around 40,000 Vietnamese Die Of Cigarettes A Year

VietNamNet Bridge – 26 May 2009

As one of the countries with the most male smokers, the number of cigarette-related deaths in Vietnam is four-fold the number of casualties from traffic accidents.

The Health Ministry’s Health Treatment and Examination Agency chief Ly Ngoc Kinh talked about the situation.

Government Decree 45 issued in 2005 stipulates a 50,000-100,000 dong fine for smoking in public sites. But it seems that this regulation is ineffective. What do you think about it?

It is impossible to implement this rule. We don’t lack regulations or sanctions on smoking, issued by the government and the Health Ministry, but they cannot be implemented effectively.

Not only in this field, in other areas people don’t obey the rules. For example, may people cross the road on a red light or they don’t wear helmets.

Why don’t people obey the ban on smoking at public sites?

Cigarettes are allowed to circulate in the market. It is very difficult to issue measures against cigarette smoking because we can’t ban them like drugs, only educate people to help them understand the danger and change their behaviour.

Moreover, profit from cigarettes is huge, only behind oil and alcohol, so producers seek every way to attract smokers.

How can other countries ban smoking at public sites?

Our sanctions are not strong enough. In Hong Kong, the fine for smoking at public sites is HK$5,000, equivalent to 11 million dong. They have smoking supervision teams at public sites.

In Vietnam, this job is assigned to police officers or guards but they don’t do it because the fine is very small, 50,000-100,000. If we impose higher fines and pay them commissions, the ban will be effective.

Moreover, many people are not familiar with living under and following the law.

Vietnam forced cigarette producers to print warnings on cigarette packs. How will this help change people’s awareness?

Most people have only vague understanding about the harms of cigarettes to health and they lack knowledge about diseases caused by cigarettes.

The warning accounts for around 30 percent of the area of a cigarette pack, and it is not strong enough: “Smoking can cause cancer”.

The warning would be better if it was expressed in an image.

It has been suggested that the warning contain an image but it has not been done yet. Why?

This issue has been discussed at many seminars. Many people think that this task is simple and useful but because of different reasons, especially strong reactions from cigarette producers, the implementation has been delayed.

Cigarette producers say that it is costly or they don’t have suitable technology to print warnings with images. But exported cigarette products have warnings with images. We will try to enforce this in 2010.


Quit Smoking Helps to Prevent Influenza

25 May 2009In view of the recent emergence of human swine influenza (Influenza A H1N1) worldwide, a spokesman of the Department of Health (DH) urged members of the public to quit smoking, one of the best preventive measures against influenza.

“Research studies show a higher risk of influenza infections among smokers when compared with nonsmokers.

“Also, mortality rate of influenza among smokers is higher than that of nonsmokers,” the spokesman said, adding that smoking cessation among smokers is essential in preventing influenza.

Adopting healthy lifestyles and maintaining good personal hygiene are also effective measures to prevent influenza, he added.

Starting May 27, DH will launch a series of smoking cessation roving exhibition in various districts to strengthen public awareness of harmful effect of smoking, and enhance their knowledge of smoking cessation.

Visitors to the roving exhibition will be able to acquire a better understanding of perils of smoking and secondhand smoke, proper ways to quit smoking as well as tips and available channels to quit smoking.

The most up-to-date information about drugs used for smoking cessation is also displayed at the exhibition.

Admission is free.

Details of the exhibitions are as follows:

Venue Date
Cityplaza, Island East May 27 – 30
Wonderful Worlds, Whampoa, Hung Hom June 4 – 7
Kingswood Ginza, Tin Shui Wai June 18 – 21
Olympian City, Tai Kwok Tsui July 30 – August 2
Citygate, Tung Chung August 13– 16

In addition, DH’s Tobacco Control Office has launched an Interactive Online Cessation Centre (IOCC) since February 2009. It provides a virtual platform for smokers to quit smoking. The web-link is

IOCC comprises four components, namely “Online Quit Plan”, “Information on Smoking Cessation”, “Tips to Quit Smoking” and “Game Zone”.

In the “Online Quit Plan”, tailor-made email prompts will be sent to registered users at appropriate times. Quitters can also print out tailor-made calendar to boost up their confidence in quitting smoking.

“Information on Smoking Cessation” introduces correct methods of quitting smoking and elaborates various smoking cessation medications.

“Tips to Quit Smoking” provides smokers with 10 useful tips to quit smoking whereas interactive online games in “Game Zone” help youngsters cultivating smoke-free culture.

The spokesman noted that a total of 83 smokers have registered to use IOCC by the end of April 2009.

Apart from DH, the Tung Wah Group of Hospitals and the Hospital Authority also provide a number of smoking cessation services comprised of combined counseling and pharmacotherapy to assist smokers to quit smoking.

Please call DH’s Smoking Cessation Hotline 1833 183 for enquiries related to smoking cessation.