http://www.theheart.org/article/1318775.do

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Opening a gold mine: Industry targets women in emerging nations

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Minister of death” takes Holland back to the dark ages

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

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

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

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

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

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

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

“Let’s hope we can turn around what is happening in the Netherlands,” he concluded.