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September 9th, 2011:

Public health suffers as Indonesia ignores calls for tobacco reform

Smoking Tigers: India and Indonesia represent the biggest challenges to global tobacco reform

Indonesian cigarette vendors at a recent rally in Jakarta, protesting government talks over a tobacco-control law. Thousands of vendors were organized and deployed by an Indonesian tobacco trade group.

Indonesian cigarette vendors at a recent rally in Jakarta, protesting government talks over a tobacco-control law. Thousands of vendors were organized and deployed by an Indonesian tobacco trade group.

On Monday, December 27, 2010, Noor Atika Hasanah, a petite 28-year-old secretary in Jakarta, updated her Twitter feed. From her bed at the Jakarta Respiratory Centre clinic, she wrote: “To smoking parents, please do smoke as far as possible from your children … so that they won’t get lung cancer.”

Atika’s own lung problem had her down again, recalled her brother Faisal Rizal. Her parents had checked her into a clinic. Later, Atika wrote that she was still waiting for a transfer to a bigger hospital.

On Thursday at 5:35am, the move happened and Atika notified her Facebook friends: “Noor just checked in @PROF. DR. SULIANTI SAROSO hospital.” A friend wrote back, “Please don’t stay too long …. Get well soon sis!”

Noor Atika Hasanah passed away later that day.

Five months after Noor Atika Hasanah’s death, Rizal said Atika Hasanah’s passing was “because of God’s will. The cigarette smoke is only the pelengkap penderita.” He used a Bahasa Indonesia grammatical term which means “direct object.”

Atika’s chronicling of her illness offered friends and family an unusual glimpse at the consequences of runaway tobacco consumption in Indonesia, yet her death to tobacco-related disease is not unusual in one of the world’s last holdouts against signing the World Health Organization’s treaty to limit the tobacco industry’s influence by restricting tobacco advertising and raising excise taxes.

With a population of around 240 million and weak government regulations, Indonesia is one of Big Tobacco’s smoking giants. As of 2009, 28 percent of Indonesian adults were smokers and more than half of men smoke, according to the World Lung Foundation.

Around 200,000 people die each year in Indonesia because of smoking-related sickness. At least 25,000 of the dead are like Atika — young, female and passive smokers, according to the WHO.

A strong habit
Atika’s story went little noticed outside her circle of friends. That’s a sharp contrast to Aldi Rizal, who in 2010 became global sensation at age two, shown on television news and internet video puffing away at some of the 40 or so cigarettes he consumed each day. The media attention embarrassed the government, which quickly paid for medical help needed to cure his addiction.

But the quick attention to the smoking toddler could not hide a startling number: In 2006 — the last year for which survey data is available for Indonesia — the prevalence of smokers ages 13-15 was 38 percent, one of the world’s highest per-capita rates of smoking among children.

Tobacco’s influence on the politics of smoking in Indonesia is punctuated by what’s happened to people like Atika. She had often complained about her boss and colleagues who smoked non-stop. She was employed by a government-sponsored cooperative for villagers, where she often worked late, surrounded by second-hand smoke.

Her father also smoked at home, but quit in 2007.

As a country, however, Indonesia does not appear ready to kick the cigarette habit. Anti-tobacco and health activists blame a combination of ineffective Indonesian politicians and the lobbying clout of global tobacco interests.

Indonesia is the toughest test on the planet for health advocates who, after decades of winning tobacco restrictions in the United States and other developed nations, now must fight deep-pocketed multinational cigarette manufacturers in emerging markets and developing nations — regions that have grown to become the industry’s key source of new revenue.

The Indonesian government has consistently refused to control tobacco advertisement. Indonesian legislators can’t even agree on enforcing their own, limited tobacco law — the 2009 Health Law that includes limited regulation of cigarette advertising. Anti-tobacco activists say this is because tobacco’s influence touches all walks of Indonesian life, from politics to pop music and the media.

In examining tobacco in Indonesia, the International Consortium of Investigative Journalists found that cigarettes have become so much a part of everyday life that politicians don’t feel rushed to address massive electronic billboards hawking cigarettes along busy streets. No one has moved against brazen marketing like point-of-sale displays featuring mini-skirted young women at rock concerts, even in front of children’s playgrounds. And few in government thought twice about a cigarette company’s sponsorship of the summit of Southeast Asian defense ministers in May 2011. Billboards for the summit were shown prominently throughout Jakarta.

“The tobacco lobby is smart. They’re adaptive. With their social responsibility campaigns, they could get a lot of parties to support them,” said Todung Mulya Lubis, a lawyer and anti-tobacco activist. “Grants from Sampoerna Foundation or Djarum Foundation could easily raise the ‘ewuh pekewuh’” — a Javanese term for not criticizing someone in public.

In Indonesia, tobacco is an old, strong tradition. In the 1880s, tobacco traders in Kudus, on Java Island, the most important area in the Dutch East Indies, mixed cloves and tobacco, creating kretek cigarettes. The name is an onomatopoeic term for the crackling sound of burning cloves. Kretek now means cigarette in Indonesia, with four leading manufacturers: Sampoerna, Djarum, Gudang Garam and Bentoel. Almost 90 percent of Indonesian smokers puff kretek.

Indonesia’s particular — and plentiful — smokers are so valuable that in 2005 Phillip Morris International paid more than $5 billion for 97-percent ownership of the Sampoerna brand. British American Tobacco followed in 2009 with $494 million for an 85-percent stake in the Bentoel brand.

The Sampoerna family established PT Hanjaya Mandala Sampoerna Tbk. in 1913 and continues to help Phillip Morris manage it. Putera Sampoerna, grandson of company founder Liem Seeng Tee, was until recently chairman of PT Hanjaya Mandala Sampoerna Tbk., while also running his Putera Sampoerna Foundation.

Power of the Press
In the Sampoerna family, Phillip Morris has an ally tied closely to Indonesia’s political and media hearbeats.

In June 2006, two years after Susilo Bambang Yudhoyono won the presidency, the Sampoerna family started Jurnal Nasional, a daily newspaper in Jakarta. Political opponents of Yudhoyono – even journalists who work for paper – say the publication’s content is controlled from the Merdeka Palace, Indonesia’s White House. Sunaryo Sampoerna, an art collector and a nephew of Putera, was chairman of PT Media Nusa Perdana, which publishes the newspaper.

The flow of money from the Sampoernas to Jurnal Nasional appears to have stopped after George J. Aditjondro, a scholar and an anti-corruption crusader, revealed connections between Yudhoyono and the newspaper in his book Membongkar Gurita Cikeas – “Uncovering the Cikeas Octopus,” published in December 2009. (Cikeas is the residence of President Yudhoyonos’ family in southern Jakarta.) The book created an uproar as Yudhoyono had won the presidential race on an anti-corruption campaign. Sunaryo Sampoerna stepped down from the newspaper board in the January 2010 shareholder meeting.

The Putera Sampoerna Foundation is also into journalism, with its Adiwarta Sampoerna Award for reporters covering legal, arts, business and environmental matters. Award ceremonies were always filled with Sampoerna banners, logo and souvenirs. The juries have included Sampoerna executives.

“On top of their advertising and sponsorship, the journalist award is a very effective method to reach out to the subconscious of journalists,” said Wahyu Dhyatmika, leader of Jakarta’s Alliance of Independent Journalists.

Another thread in the Sampoerna – Yudhoyono connection: Putera Sampoerna hosts Yudhoyono’s youngest son, Edhie Baskoro, the Democratic Party secretary-general, in an office inside his Sampoerna Strategic Square tower, in Jakarta. The 27-year-old politician has a whole floor for himself.

Yudhoyono “is not a smoker, but he’s a friend of the cigarette companies,” Todung Mulya Lubis said.

Yudhoyono’s spokesman declined requests for comment from ICIJ, and Sampoerna family members and foundation officials declined requests for interviews about Jurnal Nasional and the journalism competition.

Further punctuation of the relationship between Sampoerna and Yudhoyono are the numbers 234 and 9, which show up often in the tobacco family’s story and on the license plate of the Rolls Royce that Sampoerna was once allowed to routinely park at Merdeka Palace, according to journalist Wisnu Nugroho, who chronicled the tobacco baron’s visits to President Yudhoyono.

234 is a special number for the Sampoernas. Putera Sampoerna’s grandfather, Liem Seeng Tee, was an immigrant from Hokkien, in southern China, who landed in Java and set up his tobacco company in 1913. Seeng Tee was superstitious. He named his most famous kretek brand 234 — Djie Sam Soe in the Hokkien language. Mathematically, 2+3+4 equals nine — what Sampoerna has said is his lucky number. Jurnal Nasional’s first office on Pramuka Street in Jakarta was also numbered 234.

When the Dutch East Indies became Indonesia at the end of World War II, Seeng Tee changed his family name to “Sampoerna.” In Malay the word means “perfect.”

Don’t Talk About Cigarettes
Tulus Abadi, coordinator of the Indonesian Consumers Foundation, which campaigns for tobacco control, recalls the visit to the Merdeka Palace by a delegation of anti-tobacco advocates whom he supported. As they met with First Lady Kristiani Herrawati Yudhoyono, she told the group she’d help them, as long as they did not talk about cigarettes.

On May 31, 2008, a World No Tobacco Day, Mrs. Yudhoyono also made a speech at the Merdeka Palace. She said cigarette advertisements were misleading and encouraged teenagers to start smoking. She reminded children not to smoke. But behind the scenes, said a health activist who attended the event, Merdeka Palace officials told the organizers that they should not say anything publicly about the WHO’s tobacco-control treaty.

These events sustain a suspicion among health activists that the tobacco industry has a firm grip on Indonesian policymakers.

Tobacco companies also are active financial supporters of sports and arts events and programs. They employ six million people in Indonesia, directly and indirectly, according to the Indonesian Alliance of Tobacco Societies. And tobacco companies claim that in 2009 they paid about 55 trillion rupiah in taxes — around $6.4 billion — and account for almost 10 percent of the nation’s public revenue.

Almost the Health Minister
Because of those numbers, health activists said they were suspicious of President Yudhoyono’s withdrawl of a nomination of the wife of an anti-tobacco crusader to be the nation’s health minister.

In late July 2009, Yudhoyono won a landslide re-election, with nearly 61 percent of the total vote. His new vice president was Boediono, a former central banker. On Sunday October 18, 2009, they invited Nila Juwita Moeloek, an ophthalmologist and a professor at the University of Indonesia’s Medical School, for a talk — and then offered her the position of health minister.

Moeloek later told reporters that the president and vice president talked about reaching the UN Millennium Development Goals in 2015 and that she was expected to undergo a health examination.

Moeloek told ICIJ that the president did not talk about tobacco control in their first meeting.

Moeloek’s husband, Faried Anfasa Moeloek, was Indonesia’s health minister in the late 1990s. So her appointment excited anti-tobacco campaigners, as Anfasa Moeloek is a patron of a coalition of anti-tobacco activists.

“The euphoria was reflected on our Yahoo group mailing list. We forgot that there are spies,” Tulus Abadi said.

Nila Moeloek took the presidential medical test. She had already received congratulatory phone calls and text messages on her nomination and political analysts proclaimed her health minister. But on the day she took the medical test, Kartono Mohamad, former president of Indonesia’s doctors association, was asked by Merdeka Palace officials to recommend three other names to head the health ministry.

Mohamad alerted health activists and called the Moeloeks.

“We were surprised when she was not invited to the Merdeka Palace,” Abadi said.

Yudhoyono said Endang Rahayu Sedyaningsih, a Harvard-trained medical doctor already in the Health Ministry, would be the new chief. Andi Mallarangeng, a Yudhoyono spokesman, said Nila Moeloek had a “psychological problem” and was deemed unfit for a cabinet job.

Legislators, journalists, health activists and politicians questioned the sudden change. The Republika newspaper demanded the government say why her appointment had been canceled.

Nila Moeloek told ICIJ that she was surprised and hurt by the “psychologically unfit” statement. She declined, however, to comment on the motives for the abrupt change of plans.

“I am not against the tobacco industries,” Nila Moeloek said. “I just want to protect small children. These kids still cannot decide yet. I don’t care about adults who decide to smoke. But a young boy who smokes will keep on smoking for decades.”

Later the president offered Nila Moeloek an ambassadorship, an offer she refused.

“I want to move on,” she said. “In hindsight, I feel grateful I did not get that job.”

Anfasa Moeloek, her husband, has eye cancer; she wants to spend more time with him.

A hard road for reform
There have been attempts in Indonesia to follow the spirit of the WHO tobacco-control treaty, but the initiatives have met with strong resistance.

In October, 2010, Health Minister Endang Rahayu Sedyaningsih said new regulation was being drafted to impose a ban on tobacco advertising, and require cigarette makers to print pictures of smoking-related diseases on their packs. “It must be understood there are a lot of interests at stake. That’s why we need to proceed wisely in drafting this regulation. What’s important is that we’re consistent and we make progress step by step.”

She didn’t have to wait long for the industry’s reaction. Tobacco groups soon sent waves of protesters to her ministry.

Komunitas Kretek, a Java-based tobacco group, organized rallies and launched an essay writing competition on the involvement of U.S. pharmaceutical companies in support of the anti-tobacco draft.

“Developed countries like the United States are trying to make profits through the sale of nicotine-replacement drugs. But they do business through anti-smoking campaigns,” said Komunitas spokesman Zulvan Kurniawan.

“I smoke one to two packs of cigarette a day. I’m fine with it. Smoking is okay as long as you don’t do it too much. Compare it with eating instant noodles, 12 packs a day, or drinking Krating Daeng [an energy drink], 12 bottles a day. You will also get sick,” Kurniawan said. “This draft regulation will kill farmers, workers and street vendors,” he added.

At one recent protest against tobacco regulation, colorful street vendors who often hawk tobacco at busy intersections by smoking several cigarettes at a time rallied outside the Ministry of Health. They carried a huge kretek and shouted, “Do we want to be the slaves of foreigners? Down with the foreigners!”

One protester grabbed a megaphone and spoke of the benefits of a controversial cancer treatment particular to Indonesia and tried by thousands of patients: cigarette smoke blown onto — and into — patients wrapped in wet cloth and foil. “The government should finance this research,” the protestor shouted. “Cigarettes are proven to have the potential to cure diseases.”

The Indonesian Alliance of Tobacco Societies, locally known as the AMTI, even pushed a campaign to label kreteks part of “Indonesia’s cultural heritage” and one of Indonesia’s 10 prioritized industries.

But the corporate mindset favoring tobacco now appears to cut against the public grain in Indonesia: A 2010 Indonesian Consumers Foundation survey found that 90 percent of Indonesians agree that cigarettes are addictive; 57 percent believe the government does not do enough to protect non-smokers; 88 percent had seen cigarette advertisements in the previous two weeks; and 71 percent want to ban tobacco ads.

The numbers should be enough to convince legislators to move against the industry, said Tulus Abadi, the anti-tobacco activist.

“We suggest the government control tobacco by increasing the taxes. Smokers’ numbers will drop but the government income will be compensated.”

Indonesia’s cigarette tax is about 47 percent of the price of a pack. Legally the government could increase it to 57 percent.

“These numbers speak for themselves,” Abadi said.


Noor Atika Hasanah, in one of her Facebook photos. Atika used Facebook and Twitter to update friends and family on her struggle with lung cancer. Before she died, the non-smoker insisted her illness was the result of second-hand smoke that surrounded her day and night. Atika Hasanah Family

Noor Atika Hasanah, in one of her Facebook photos. Atika used Facebook and Twitter to update friends and family on her struggle with lung cancer. Before she died, the non-smoker insisted her illness was the result of second-hand smoke that surrounded her day and night. Atika Hasanah Family

The developing world accounts for most of the globe’s tobacco related deaths. Stephen Rountree/Rountree Graphics

The developing world accounts for most of the globe’s tobacco related deaths. Stephen Rountree/Rountree Graphics

The leading cigarettes in Indonesia are called kretek -- named for the sound of the burning cloves commonly mixed with tobacco in the cigarettes preferred by 90 percent of the country's smokers. Andreas Harsono

The leading cigarettes in Indonesia are called kretek — named for the sound of the burning cloves commonly mixed with tobacco in the cigarettes preferred by 90 percent of the country’s smokers. Andreas Harsono

Girls taking photos at a tobacco-sponsored exhibit during the 2011 Java Rockin' Land concert, sponsored by the Gudang Garam cigarette brand. The 3-days event in Indonesia drew performers such as The Cranberries, Thirty Seconds to Mars, The Dirty Radicals and Good Charlotte. Tobacco companies are among the leading sponsors of live music events in Indonesia  Rocco Rorandelli

Girls taking photos at a tobacco-sponsored exhibit during the 2011 Java Rockin’ Land concert, sponsored by the Gudang Garam cigarette brand. The 3-days event in Indonesia drew performers such as The Cranberries, Thirty Seconds to Mars, The Dirty Radicals and Good Charlotte. Tobacco companies are among the leading sponsors of live music events in Indonesia Rocco Rorandelli

A sales girl hawks Djarum Black Menthol near a playground during an R&B music parade, organized by Djarum.  Rocco Rorandelli

A sales girl hawks Djarum Black Menthol near a playground during an R&B music parade, organized by Djarum. Rocco Rorandelli

From Age 2 to 7: Why Are Children Smoking in Indonesia?

He is a thoroughly modern icon: the cherubic toddler now known around the world as the “smoking baby.” More than 13 million people have watched a YouTube clip of the two-year-old puffing hungrily on cigarette after cigarette, twirling them in his hands. But while many viewed this video with amusement and perhaps some shock, it appears this “smoking baby” is just the tip of the iceberg.

Indonesia, the fourth most populous country on earth, appears to be in the throes of an uncontrolled tobacco habit. It is a place where domestic and international tobacco companies are able to operate ways they haven’t been able to in the U.S. for 41 years.

This is a country where, as soon as a visitor steps off the plane, he is bombarded with cigarette ads on billboards and logos; and where, as “2020” found out, there is more than one “smoking baby.”

In a tiny fishing village in Eastern Java, lives an adorable two-year-old boy named Chairul. Soon after awaking from a nap, he lights up with the help of his own grandfather. The grandfather says he allows Chairul to smoke because it tastes good, “like bread with chocolate.”

As Chairul smokes beside him, his grandfather said he doesn’t think it is a problem.

“He sometimes smokes two packs a day,” he said, though it appears Chairul does not inhale. Yet he puffs away, exposed to the smoke around him.

When warned about the health effects of cigarettes, Chairul’s grandfather said: “If the boy doesn’t smoke, he doesn’t feel good.” It’s all right, he said, “as long as he drinks enough coffee with his cigarettes.”

As strange as that may seem, Chairul is no fluke. In a town a few hours to the south, “20/20″ found a seven-year-old boy who also smoked while his family looked on.

His name is Maulana, and his mother said he has been smoking since he is two, but she hopes he quits when he goes to school this year.

As to why she allows her son to smoke, Malauna’s mother said: “I can’t just stop him abruptly, because he gets weak and cries. It has to be done slowly.”

It is estimated that about a million children in Indonesia under the age of 16 smoke, and that one third of Indonesian children try smoking before the age of 10. In Indonesia, it is perfectly legal for a child of any age to buy and smoke cigarettes.

This, despite hundreds of international studies showing tobacco is addictive and harmful. The World Health Organization says tobacco kills more than five million people annually.

In the U.S., tobacco companies haven’t been allowed to advertise on TV in 41 years. So, unable to market freely at home, big tobacco has increasingly turned overseas, where they are using the very tactics to reach young people that have long been banned in America.

Marketing Cigarettes to Young People

In 2008, Altria, the parent company of Philip Morris USA, spun off its international operations, Philip Morris International. In 2005, PMI had acquired Indonesia’s third largest tobacco company, Sampoerna. Selling a mix of Philip Morris brands and popular Sampoerna brands, PMI is now the number one tobacco company in Indonesia, with an estimated 30 percent of the market.

But to what extent does PMI market to young people? ABC News obtained internal documents from 2005, when PMI was acquiring Sampoerna. These documents target one Indonesian brand, A-Mild to become the “destination brand… for aspirational young adult smokers.”

A-Mild “does not just understand the spirit of the new generation of Indonesians, but it is also their spirit / their voice!” said another document.

ABC News wanted to talk to Philip Morris International, whose headquarters are in New York. After they declined, they sent this e-mail:

“We support the strict regulation of tobacco products. In Indonesia we have repeatedly urged the government to introduce tobacco regulation that bans sales to minors, restricts advertising and sponsorship and mandates stronger health warning requirements.”

Critics say that PMI’s advertising, packaging and marketing is seen by children. Tobacco companies in Indonesia routinely sponsor rock shows in outdoor venues and on television, in ads that feature attractive young people.

In a second e-mail, Philip Morris International wrote to ABC News:

“We have also taken several steps in the absence of comprehensive regulation, such as restricting access to events we sponsor to people aged 18 and above, requiring proof of age with a valid ID card.”

ABC News also found tobacco billboards and even a kiosk near a school, where students were able to buy individual cigarettes for about a dime.

PMI responded: “Clearly cigarettes should not be sold to minors, whether individually or in packs. This practice highlights the need to have a minimum age law in place and, importantly, enforced. We will continue to encourage the Indonesian government to introduce a ban on sales to minors in the shortest possible time frame.”

“Philip Morris [International] has maintained a standard public stance, that it does not market to children, that it does not want children to smoke,” said tobacco control activist Mary Assunta, who has worked in Indonesia. “But the evidence on the street says otherwise, that they need to market to children, because we know that the bulk of smokers start smoking when they are children. You’ve got to catch them young.”

Matthew Myers, the president of the Campaign for Tobacco Free Kids, calls Indonesia “the Wild West for the tobacco industry.”

“We see marketing practices that we haven’t seen in the west in 20, 30 and 40 years,” he said.

Anti-tobacco legislation has died in parliament, tied up by red tape, and, critics say, tobacco industry influence. This is a place where ” pro-tobacco” rallies are organized by tobacco farmers and even religious groups. Recently, thousands surrounded the presidential palace protesting a new bill that would ban cigarette advertising and sponsorship, prohibit smoking in public and add graphic images to packaging.

In 2009, there was even a clause taken out at the last minute from a health bill saying cigarettes are addictive. The Center for Public Integrity’s International Consortium of Investigative Journalists, in conjunction with ABC News, has reported on barriers to passing tougher anti-tobacco legislation.

“Indonesia is the perfect example of what happens when you let the industry do whatever it wants to market to young people and the government does nothing to counteract it,” said Matthew Myers. “It’s a deadly combination. A government who’s doing nothing to protect its citizens and a tobacco industry that will market to anybody of any age.”

Indonesia’s Minister of Health, Dr. Endang Sedyaningsih, who studied at Harvard University, said more than 400,000 people die in Indonesia every year of tobacco-related causes. But she said she can’t push too hard for change, for fear her efforts will backfire if she does.

Can Children Quit Smoking?

Referring to the tobacco companies, she said: “I just don’t like them, but… I don’t talk loudly about this. If I push too hard then I will get a strong reaction.”

Dr. Endang cited a troubling statistic: “I can say sadly that children aged 10 to 14 who start smoking is actually rising from 2007 to 2010.”

And then there is that famous “smoking baby.” His name is Aldi Rizal and he is now a chubby four-year-old who lives in rural Sumatra with his family in a one-room hut.

After the video aired, embarrassed local health officials set him to rehab in Indonesdia’s capital, Jakarta. Now, Aldi’s mother says he is no longer smoking. At least for now, she told “20/20.”

“If I don’t buy him toys, he threatens to start smoking again,” said his mother.

Aldi promised not to smoke, though his mother said she caught him with a cigarette recently because people in town offer them to him when he visits.

But living in this environment, where cigarette companies have such free rein to transmit their message, quitting for the children of Indonesia may be easier said than done.

ABC News teamed with the Center for Public Integrity’s International Consortium of Investigative Journalists (ICIJ) in reporting on the tobacco industry in Indonesia. This week, ICIJ released a report on the barriers to passing tougher anti-tobacco legislation in Indonesia.

Philip Morris International is the leading international tobacco company, with tobacco products sold in approximately 180 countries. In 2010, PMI captured an estimated 16 percent share of the total international cigarette market outside of the U.S., excluding China. In 2010, Philip Morris International reported worldwide revenues of $27 billion and an operating income of $11.2 billion, according to the company’s annual report. PMI spends more than $200 million marketing in Indonesia, and overall sales have increased by 25 percent in the last decade. For more information about smoking in Indonesia and Philip Morris International visit these websites:

Smoking’s last gasp saloon

Smoking's last gasp saloon

Dr Raymond Ho, head of the Department of Health’s Tobacco Control Office (5th left), announces in August Hong Kong’s lowest smoking figures in 30 years. With him are officials and professionals engaged in promoting smoking cessation, standing in front of a poster showing a slogan for Hong Kong to be a smoke-free city. Photo by Red Door News, Hong Kong

Hong Kong is on the verge of becoming the first place in the world in modern history where less than one in 10 adults smokes. If it achieves it, health experts internationally will be watching closely to see if the city can effectively eradicate the habit altogether, reports Simon Parry.

Imagine a city where smokers were once everywhere but are now almost extinct; a place where more than one in five adults once smoked but where now there are so few smokers left that shops no longer stock cigarettes, lighting up is a social disgrace, and the habit dies a sudden, quiet death.

That city might well be the Hong Kong of the near future, experts believe, after the city in August recorded what may already be the world’s lowest rate of smokers at just 11.1 percent of the adult population. Today, just 3 percent of women and 19.9 percent of men smoke.

With the quirky exception of Bhutan, where smoking is officially banned as bad for Buddhist karma, nowhere in the world are smoking levels so low. Hong Kong’s male smoking rate compares to 35 percent in Singapore, 48 percent in Vietnam, 33 percent in both the US and Germany and 51 percent on the Chinese mainland.

The figure is all the more remarkable when you consider that three decades ago, nearly one in four of all Hong Kong adults smoked. But recent years have seen a precipitous decline in smoking rates in the city that have taken the war against tobacco to a potentially decisive phase.

Punishing tax rises, the expansion of no-smoking areas and a host of initiatives to help people quit have seen a drop in the number of smokers to the point where experts like Judith Mackay believe Hong Kong is on the verge of an “end game” in its battle to curb smoking.

“Hong Kong is in a very interesting position,” said Dr Mackay, senior advisor to the World Lung Foundation and the World Health Organization (WHO), who has worked closely with the Hong Kong government on tobacco control over the past three decades.

“There are a couple of places including Hong Kong beginning to look at what we are confidently calling the end game.

“New Zealand has set a target of 5 percent and has pledged to get there by 2025. But Hong Kong has been challenged by the WHO to be the first place in the world to get into single figures so that’s what we are trying to do.”

Reaching single figures means more than just numbers. It represents a potential tipping point – a level at which a critical mass of smokers no longer exists – that could change the whole dynamic when it comes to social tolerance of smoking.

“We don’t know what will happen we get down to single figures,” said Dr Mackay. “Do you get an absolutely hardened core of smokers who cannot quit, or do you actually find that the societal norms change and there is even perhaps a quicker drift down?

“We simply don’t know and there’s no experience in the world that can help us with that. These truly are unchartered waters.”

For Dr Mackay – who began her campaign against smoking in 1984 and was once named by the tobacco industry as one of the most dangerous people in the world – the change in Hong Kong over the past three decades has been astonishing.

“There has been a sea change,” she said. “When I started with this work, you could smoke anywhere in Hong Kong. There were massive billboards, advertising on TV, advertising on the radio and ubiquitous marketing and promotion.

“There were no smoke-free areas. You could smoke in cinemas, on buses, you could smoke anywhere. This has just been an incredible public health move.

“Some people would regard 30 years as an unacceptable length of time to get these things done but if you look at the history of public health epidemics, it takes you anything from 50 to 100 years to go from identification of the problem to really getting on top of it. Smallpox went on forever. Even polio we haven’t got on top of.”

Hong Kong has one curious sociological trait in its favor in battling smoking, according to Dr Mackay: A combination of relatively low male smoking rates similar to those in western countries, and extremely low female smoking rates in common with Asian countries.

Much credit, however, is owing to both the pre-handover colonial government and the current administration for pursuing vigorous anti-smoking initiatives over the years, she said, with efforts in the past four years being particularly effective.

“What Hong Kong has done most recently is introduce the whole smoke-free areas initiative plus the fact we have had tax increases – it’s as simple as that,” said Dr Mackay. “Plus we are now seriously beginning to introduce assistance with quitting for smokers.”

However, she insisted there was no room for complacency. “The tobacco industry has predicted we would never get down into single figures, so we are out to prove them wrong,” she said. “But what that does mean is that there is no easy route from now on.

“We have got to keep up all our momentum and defences and attack, to use warlike terms. There must be no sense of complacency or sitting back and thinking ‘Really good figures. We’ve done it and everything’s fine’.”

Dr Mackay said it was “inevitable” there would be a backlash from the tobacco industry and pointed out how they had launched actions in jurisdictions around the world to challenge moves towards smoke-free areas.

“We got our smoke-free legislation in just in time,” she said. “If we tried to do it two years later, we’d have had years of seeing it challenged through the courts.”

Dr Raymond Ho Lei-ming, head of the Hong Kong Department of Health’s Tobacco Control Office, said if Hong Kong succeeded in bringing smoking levels down to under 10 percent of the adult population, it would be a significant landmark.

“We are trying to set a new cultural norm,” he said. “When we set up law enforcement and give out HK$1,500 tickets for breaching smoking laws, we are not thinking of it just as a punishment.

“We think most people are law abiding in Hong Kong and it is just a matter of educating the public and also the smoking offender so they comply with the law. Once we do that I think there will be a new norm or movement to strive for a smoke free environment.

“Once we get to below 10 percent, it is difficult to find a ‘buddy’ or someone to support you in your habit. We know cigarettes are offered by buddies. That factor may drive numbers down to a lower level even more quickly.”

Asked if he believed a day would come when the sale of cigarettes would be outlawed in Hong Kong, Dr Ho said: “That would depend on society and whether we reach a consensus. There are talks of ‘end games’ here and overseas.

“New Zealand wants to be smoke-free by 2025. Finland wants to go smoke-free by 2040 and in Singapore they were thinking of changing the law so that after a certain age – if you are born after 2000 – you are not allowed to be sold cigarettes.

“So there are different plans of end games but really you have to look at the individual situation of the jurisdiction and the cultural acceptance of banning it outright.”

One of the most important recent developments has been the introduction of city-wide smoking cessation services with free medication and anti-smoking aids, said Dr Ho. Hong Kong was also pioneering a mobile acupuncture service for people trying to quit.

“We don’t know how effective acupuncture is as a smoking cessation approach,” he said. “Generally speaking, giving up smoking is not easy. The success rate after six months or even one year is only around 40 percent. People usually have to try a few times.

“We want to assess whether acupuncture helps Chinese people to quit. It has been assessed previously on Western populations. We want to see how good the method is on the Hong Kong Chinese population. We started this project in April 2010 and we are collecting data to see how effective it is.”

Other measures – some of them in force in other jurisdictions – are being looked at, including the possibility of banning smoking within three meters of public buildings, at taxi and minibus stands and in al fresco dining areas.

The government is also looking at a requirement for plain packaging for cigarettes, the adding of numbers for stop-smoking lines on packets and a ban on displays of cigarettes so they are kept in shuttered cupboards out of sight of shoppers.

Those tactics could be pivotal in determining whether Hong Kong makes the leap from a low-smoking to a no-smoking city. “We still have just over 650,000 smokers,” pointed out Dr Ho. “We have more to do if we are to bring the numbers down further.”

Plain packets would cut number of women smokers, says report

9 Sept. 2011

Wrapping cigarettes in plain packaging and banning the sale of colourful, branded packs could help to reduce tobacco consumption among smokers, especially young women who smoke, a study has found.

Researchers found a marked reduction in tobacco consumption among a group of 48 smokers who were given dummy, plain packs of cigarettes to use over a two-week period rather than branded packets.

The findings lend support to a controversial suggestion that tobacco companies should be forced to abandon their attractively marketed packaging and adopt plain packs in dull colours with prominent health warnings. The Government is expected to announce a formal consultation on the proposal later this year.

Scientists at Stirling University’s Institute for Social Marketing carried out the tests of plain cigarette packaging on a sample of young smokers from Glasgow, aged between 18 and 35, who completed detailed questionnaires about their attitude towards the plain packs they were given to hold their usual brands of cigarettes.

“This pilot naturalistic study suggests that plain packaging could potentially help to reduce tobacco consumption among some young adult smokers, and women in particular,” the researchers conclude in a study published yesterday in the journal Tobacco Control.

The plain packets were rated more negatively than branded packets, cigarettes were taken out less often, handed out less frequently and the packs were hidden more often, said Crawford Moodie, the study’s lead author.

“Despite the small size of this study it adds an important real-world dimension to the research on the way smokers respond to plain packaging,” Dr Moodie said.

“The study confirms the lack of appeal of plain packs, with the enjoyment and consumption of cigarettes being reduced. We’re now looking to build on this research to understand more about the impact of packaging on smokers,” she added.

Gerard Hastings, director of the Stirling Institute, said that although the pilot study was too small to produce statistical significance, it was indicative of being effective in cutting down tobacco use. “Plain packaging is off-putting. It makes smokers behave in a negative way towards their habit, it reinforces that negative attitude and it’s more pronounced in women than in men,” he said.

Australia is set to become the first country to introduce plain packaging next year. The tobacco industry is opposed to the plan, arguing that it encourages the sale of contraband cigarettes and infringes their trademarks.