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June 2nd, 2016:

Plain-packaging push for tobacco products

As Beijing marked the first anniversary of China’s toughest anti-smoking measures, experts called for stronger regulations to safeguard the population.

The World Health Organization and leading health experts in China are calling for the country to follow the global trend and promote plain packaging and graphic warnings on cigarette packs to reduce tobacco use.

The organization’s call for all countries to prepare for plain, or standardized, packaging of tobacco products came as Beijing marked the first anniversary of an anti-smoking law, which came into force on June 1 last year, and World No Tobacco Day, which fell on May 31.

“Plain packaging is an evidence-based measure that can save lives and protect public health,” said Bernhard Schwartlander, the organization’s representative in China.

“Plain packaging makes tobacco products less attractive, stops tobacco companies using the pack as a marketing tool, and increases the effectiveness of health warnings.

“WHO recommends plain packaging as part of a comprehensive approach to tobacco control: it works best alongside other tobacco-control measures, including comprehensive anti-smoking laws, bans on tobacco advertising, promotion and sponsorship, raising tobacco taxes and large, graphic health warnings,” he said.

Wu Yiqun, vice-director of the ThinkTank Research Center for Health Development, an NGO in Beijing that is committed to tobacco control, said: “China lags behind many other countries in promoting plain packaging and graphic warnings.

“Most major countries require graphic warnings to be printed on tobacco packs, but there is no sign that similar measures will be adopted in China anytime soon. We cannot wait. We must take action right now.”

China is the world’s largest producer and consumer of tobacco products, and has the world’s largest population of smokers-more than 300 million people. Tobacco-related illnesses cause more than 1 million deaths every year in the country, and more than 700 million people are exposed to second-hand smoke, which poses a health risk, according to the National Health and Family Planning Commission.

Stringent regulations

Beijing’s anti-smoking regulations, the toughest among the 18 Chinese cities in which controls have been implemented, ban smoking in all indoor public areas and workplaces, and in a number of outdoor spaces, such as areas near children’s hospitals.

Violators face fines of up to 200 yuan ($30), 20 times higher than those levied under a lessstringent regulation adopted in 1996.

Fang Laiying, director of the Beijing Municipal Commission of Health and Family Planning, said smoking in some public places, such as restaurants, has decreased greatly over the past year.

Moreover, the city’s health authorities have imposed fines totaling more than 1 million yuan on premises and individuals who violated the regulations.

Meanwhile, a recent survey found more than 46 percent of smokers plan to quit, compared with less than 12 percent before the capital implemented the smoking ban, Fang said.

Mao Qun’an, a spokesman for the National Health and Family Planning Commission, the nation’s top health authority, said the measures have won great public support, produced satisfactory results in terms of tobacco control and paved the way for national tobacco-control regulations.

Other important steps in the past year include a rise in tobacco tax, and therefore retail prices, announced by the Ministry of Finance in May last year, which has resulted in a reduction in overall tobacco consumption. In addition, stronger restrictions on tobacco advertising came into effect in September.

Global measures

Plain packaging refers to “measures to restrict or prohibit the use of logos, colors, brand images or promotional information on packaging other than brand names and product names displayed in a standard color and font style”, according to WHO.

In December 2012, Australia became the first country to fully implement plain packaging, while France and the United Kingdom began the process on May 20. New Zealand and Norway have also announced that they will remove branding from cigarette packs. Ireland is also preparing to introduce the measure, while other countries are exploring the option, WHO said.

“Plain packaging is fast becoming a global trend,” Schwartlander said.

“There is an opportunity for China to take a step in the right direction toward plain packaging with the adoption of a strong, comprehensive national smoke-free law, including the introduction of graphic health warnings.”

The National Health and Family Planning Commission proposed a national tobacco control regulation in 2014, which was submitted to the State Council for approval in the same year.

“The legislation is at the end stage and may be completed before the end of the year,” said Mao, the commission’s spokesman, at an international conference in Beijing on May 30 to mark World No Tobacco Day.

Wu Yiqun, who participated in the revision process, said the latest draft has not yet been released to the public, but it is more lenient than the measures adopted in Beijing, and plain packaging or graphics warnings were not mentioned in the paper.

Reducing consumption

Wu Ming, a professor of public health at Peking University’s Health Science Center, said putting images on tobacco packs that depict the downside of smoking, such as cancer-ridden lungs and yellowed teeth, can greatly reduce tobacco consumption and is a highly effective measure to help prevent young people from picking up the habit.

“However, at present cigarette packs only carry a few small characters that read ‘smoking is harmful to health’,” she said.

Graphic warnings have been adopted in more than 80 countries and regions, including the Hong Kong Special Administrative Region, and in many countries images cover more than half of the surface area of the packs, she said.

WHO’s Schwartlander said it is crucial to make the warnings more hard-hitting: “The current warnings on packs in China are woefully inadequate: they are ineffective at informing smokers about the harm caused by smoking and do little to warn young people off taking up the habit.”

According to Wu Yiqun from ThinkTank, compared with plain packaging, which prevents tobacco companies from promoting smoking through the designs on packaging, graphic illustrations of the damage caused by smoking have a greater effect on smokers, regardless of origin or culture, and is effective with less-educated or illiterate people.

In addition, the photos also reduce sales of tobacco products bought as gifts, which is one of the major reasons for their overwhelming prevalence in China, she said.

“Printing graphic health warnings is the most economic and effective way of generating publicity for tobacco-control measures,” she added.

However, she conceded that it’s highly unlikely that legislation to enforce plain packaging or the inclusion of warning graphics will be implemented in the near future. The biggest obstacle has been resistance from the nation’s powerful tobacco industry, which contributes more than 6 percent of China’s annual tax revenue.

“The government may think a decline in tobacco sales will affect economic development,” she said. “But we cannot rely on money that is generated at the cost of people’s health. We hope the government will continue to promote tobacco control for the public good.”

Standardized packs save lives

・ Plain packaging refers to “measures to restrict or prohibit the use of logos, colors, brand images or promotional information on packaging other than brand names and product names displayed in a standard color and font style”.
・ In December 2012, Australia became the first country to fully implement plain packaging. On May 20, France and the United Kingdom both began implementation of plain packaging. On Tuesday, New Zealand and Norway became the latest countries to announce they will remove branding from cigarette packs.
・ By the end of last year, graphic warnings on packaging had been adopted in 85 countries and regions.
・ Studies undertaken after the implementation of pictorial package warnings in Brazil, Canada, Singapore and Thailand consistently show that they significantly increase people’s awareness of the damage caused by tobacco use.

Illegal cigarettes and tobacco robbed Treasury of £20bn over past decade

Coventry retailers worried possible changes to branding of packaging could lead to even more illegal products being smuggled in

Smugglers bringing illegal cigarettes and tobacco in to the country have robbed the Treasury of £20billion over the past decade.

The figure was revealed by HM Revenue & Customs (HMRC) after an estimated £2.1bn was added to that total in 2014/15.

And retailers in Coventry are worried that possible changes to the size and branding of packaging could lead to even more illegal products being smuggled in to the country.

Around ten per cent of cigarettes and 35 per cent of roll-your-own tobacco were smuggled into the UK in the past year, with many ending up on the shelves of shops and outlets up and down the country.

A recent undercover investigation in Coventry by Japan Tobacco International (JTI) found 13 shops selling illegal cigarettes or tobacco, which had no UK tax duty paid on them.

Many of the products recovered were also found to be counterfeit.

And Narinda Sharda, who runs Earlsdon News, believes there could soon be even more smuggled products doing the rounds in the coming months.

He said: “I’m concerned that illegal products can have a detrimental effect on traders, government duty and there’s also the health issue.

“There is talk of there being bans on packs of more than 20 cigarettes and also 20g bags of tobacco only and I think this could lead to more and more people smuggling in to the country.

“It could see people splitting the larger bags of tobacco in to smaller ones to sell on and also people bringing in packs of say 19, 18 or 17 cigarettes to sell as they would be cheaper.

“For some retailers you already have regular customers suddenly not turning up for a couple of weeks as someone they know has bought cigarettes in to the country and then they come back again.

“Also, some tobacco that comes in to the country can sometimes have other things in it, so people that smoke them could be inhaling something they might not want to.”

Steve Wilkins, JTI’s anti-illegal trade operations director, is also concerned that more children could take up smoking as smugglers have no qualms, unlike retailers, on who they sell their products to.

He said: “The vast majority of retailers are the ‘gatekeepers’ for age-restricted products and they help to ensure that children do not get hold of tobacco products.

“Unfortunately, the criminals who sell illegal tobacco within our communities do not operate a ‘no ID, no sale’ policy and will sell to all-comers, including children.”

ECU, UNC study shows strong support for raising age to purchase tobacco products

There is strong support in all regions of the United States for raising the legal age of tobacco sales, according to a national survey conducted by researchers from East Carolina University and the University of North Carolina at Chapel Hill.

The study results, recently reported in the American Journal of Preventive Medicine, show a majority of adults support increasing the minimum legal age for tobacco product sales, and most support increasing the minimum age to 21.

“With these findings, policy makers and public health advocates can move forward knowing that people in their states support raising the minimum legal age for selling tobacco products, and that this is an issue that is not viewed as partisan,” said Adam O.

Goldstein, a UNC Lineberger Comprehensive Cancer Center doctor and member and a professor in the UNC School of Medicine Department of Family Medicine. “It seems to cross political lines, and it is one policy measure that the majority of those surveyed can agree on.”

Pitt County once was the nation’s largest producer of flue-cured tobacco, the major component of mass-produced cigarettes.

Candidates running for state House District 9, which encompasses eastern Pitt County, said they support increasing the legal age for tobacco product sales to 21.

“I don’t know that North Carolina is necessarily ready to take it up, but it’s an issue that needs to be taken up,” said Greenville urologist Greg Murphy, the district’s Republican representative.

“We are paying millions and millions in health care dollars because of the effects of tobacco use, and 90 percent of lifelong smokers start before the age of 18.”

The Campaign for Tobacco-Free Kids found that each day more than 2,500 children in the United State try their first cigarettes with another 580 becoming new daily smokers.

Murphy said that while there isn’t enough time to take up such legislation in the current short session, he thinks there should be discussions.

“I don’t want to be seen as governmental overreach, me telling everybody what to do, but when those particular actions affect other parts of our society, especially with health concerns, as not only a physician but as a legislator, I think it’s reasonable to have input,” Murphy said.

Brian Farkas, the Democrat running for the House 9 seat, said since eastern North Carolina’s history is tied to tobacco, a representative from the region should be a part of any changes in tobacco sales regulations.

“I think there’s one thing we need to be talking about in field of medicine, and that is preventative care,” Farkas said.

“Based on the data I am seeing and the report … there is potentially large savings and public health impacts by bumping it up three years, while there would be relatively minimal cost to tobacco sales.”

The joint study comes as two states recently have moved to increase the legal age of tobacco sales to 21. Hawaii became the first U.S. state to make the change on Jan. 1, and California followed suit earlier this year. Already, a number of counties and cities, including New York City, have increased the minimum legal age.

“With the strong support indicated in our data, I think we will continue to see strong momentum,” Goldstein said. “It appears likely that increasingly, lawmakers are going to be interested in doing this.”

According to a National Academy of Medicine report in 2015, increasing the legal age for purchasing tobacco products likely would lower health care costs and would prevent or delay young adults from starting smoking. The U.S. Food and Drug Administration-sponsored report predicted that raising the legal age to 21 nationally would
result in a 12-percent reduction in smoking prevalence.

“By restricting tobacco use to people 21 and older, the compelling evidence is that you have less people who end up using it. They don’t end up taking up smoking and tobacco,” Goldstein said. “And if you cut down on adolescents using tobacco, you’ll ultimately cut down on how many adults use tobacco, and then you cut down on tobacco related diseases like heart disease and cancer.”

In the study, researchers surveyed 4,880 adults ages 18 or older to learn their views on raising the minimum age of tobacco sales to 19, 20 or 21. The telephone survey was offered in both English and Spanish and conducted on landline and cellphones.

A majority of people surveyed supported raising the minimum age in all regions of the country. Levels of support ranged from 59.6 percent in a seven-state Midwestern region to 73.1 percent of residents in a four-state region of the South that included Texas and Louisiana. In the South Atlantic region, which included North Carolina, 68.1
percent of people supported an increase.

“Even in regions with historically strong ties to tobacco growing and manufacturing, a strong majority of the public, including smokers, is in favor of raising the minimum legal age of tobacco sales,” said the study’s first author Joseph G.L. Lee, an assistant professor at the ECU College of Health and Human Performance. Lee began the study as a doctoral student at the UNC Gillings School of Global Public Health.

Women, non-white adults, Latinos and non-smokers were more supportive of an increase, as were those who were older than 21.

“What we found was really an overall trend of broad support for this policy,” Goldstein said.

Hayes Hutchens, an employee of Blackbeard Cigars, which sells premium cigars and pipe tobacco, has mixed feelings about raising the legal age of tobacco sales.

“The catching point would be alcohol, tobacco, anything like that, you’re old enough to serve in the military but not old enough to make a decision about your vices?

However, my daughter just turned 21 and I wouldn’t have wanted her to use either one of them before then,” Hutchens said. Even though she’s older, Hutchens said he still doesn’t want his daughter to use tobacco.

“I wouldn’t have a problem with a 21-year-old (age limit),” he said.

Blackbeard Cigars gets the occasional college student to come in, Hutchens said.

“They tend to be more seasonal, at the beginning of the semester, around the holidays, around graduation, but they aren’t a regular customer base,” he said.

The study was supported by grants from the National Institutes of Health, National Cancer Institute and the FDA Center for Tobacco Products.

In addition to Goldstein and Lee, the study was co-authored by Marcella H. Boynton and Amanda Richardson of the UNC Gillings School of Global Public Health Department of Health Behavior and Kristen Jarman and Leah M. Ranney of the UNC School of Medicine Department of Family Medicine.

Dutch tobacco policy goes up in smoke amid political tensions

The Netherlands refuses to take significant action as ruling parties fear blowback

The Dutch are good with their teenagers. Surveys show the youngsters are the happiest in Europe, with plenty of friends, relatively little bullying at school, and few unwanted pregnancies. So it comes as no surprise to see that smoking is disappearing too among the under-16s.

A new study by the National Statistics Office shows a consistent drop over the past 20 years. In the late 1990s some 10 per cent of under-16s had already taken up the regular smoking habit – but now that figure has dwindled to just 1.3 per cent, the trend is consistently downwards.

The statistics confirm a survey by Maastricht University a few years ago which showed smoking in school – whether behind the bike sheds or elsewhere – was just not cool anymore. In sociological terms, smokers were “no longer among the most influential majority group”.

The truth though is that the Netherlands has not overnight become a society where things change automatically for the better. This transformation is directly linked to a ban on the sale of cigarettes to under-16s introduced in 2003 – combined with a rigorous no-smoking policy in schools.

In a nutshell, enforcement has worked, a proposition supported by the second part of the latest statistics office survey, which shows that young people are simply falling prey to the killer addiction later – in their 20s, when they are free to make their own life choices.

Twentysomething smokers

In fact, the figures show that the highest proportion of smokers of any age is among twentysomethings. Almost 40 per cent of them smoke, 60 per cent of them every day.

The habit falls back slightly for the over-30s, but by then – as the song says – it’s a hard habit to break. A huge 85 per cent simply continue on smoking every day to the detriment of their health, particularly as they get older.

In fairness to the dogged Dutch, those who kick the habit are relentless in their determination. Some 30 per cent of smokers who quit never smoke again, well above the European average of 21 per cent. The problem though remains. It’s just the smokers who are older.

But are smokers really victims, or is smoking, indeed, simply a lifestyle choice?

Very much the former, say Amsterdam lawyer Benedicte Ficq and lung-cancer patient Anne Marie van Veen, who are planning a court action against tobacco companies for “purposely and premeditatedly” endangering smokers’ health – something the companies will vigorously deny.

“Our point is that smokers’ ability to choose has been influenced by the addition to cigarettes of addictive substances such as nicotine and additives with the specific intention of limiting that freedom of choice”, says Ficq, who wants possible prison sentences for tobacco company executives.

“This is unacceptable on many levels but particularly when children and young adults are among those being targeted.”

Victims or not, almost one-quarter of Dutch citizens over 15 are smokers – and roughly half that number will die of smoking-related diseases at a rate of about 20,000 a year.

That raises questions from anti-smoking campaigners about why the government is choosing what they regard as easy options – scary pictures on cigarette packages and public information campaigns – rather than tough love in the form of substantial tax increases, a form of enforcement that’s been shown to work in Sweden and Australia.

Tax rise

A vocal advocate of hitting smokers where it hurts – in their pockets – is Eric van den Burg, an alderman in Amsterdam with prime minister Mark Rutte’s Liberal Party. In his opinion, smokers should face an immediate tax increase of at least €10 a packet.

Where the tobacco interests and the pro-choice lobby in the Liberals are wrong, he contends, is that not every person is capable of making an independent-minded decision about smoking. “Addicts are not free to choose – that’s what makes them addicts,” he argues.

Van den Burg also points to the inevitable voter backlash that would follow in next year’s general election were the Liberal-Labour coalition to pluck up its courage and act for what he sees as the public good by increasing tobacco taxes.

His calculation is simple: in a political landscape in which Rutte’s Liberals are being closely challenged by Geert Wilders and his anti-immigrant Freedom Party, a tax hike on fags would lead directly to the loss of two or even three crucial seats.

For Labour, the blowback would be even worse, he maintains, simply because there tends to be more smokers among people on lower incomes, typically Labour followers.

Still, such cold-hearted realpolitik couldn’t possibly be the rationale for making public health decisions that cost lives. Could it?

Tobacco looks to gain in developing world despite cancer

Less than a decade ago in the UK, it was possible to smoke in pubs and restaurants as much as you liked. Go back just a few more years, to 2002, and it was still possible to see adverts for cigarettes on billboards in the street.

Now the UK, along with Ireland and France, is following Australia’s lead in introducing plain packaging, a step that demonstrates just how far restrictions on smoking have come in a relatively short space of time.

Leave western Europe and the picture is more mixed. While smoking is in general becoming less popular and regulation is getting tougher, it remains a killer that takes the lives of 6m people each year, according to the World Health Organisation. Although wealthier countries have been successful in controlling the sale of cigarettes, lower-income nations face an uphill struggle.

“Globally [regulation] only ever moves in one direction, which is to become tighter,” says James Bushnell, an analyst who covers the tobacco industry for Exane BNP Paribas. But for some poorer countries, Mr Bushnell adds, the money required “to come up with a regulatory framework and enforce it is not there”.

There are over a billion smokers in the world, according to the WHO, with four big international tobacco companies that between them made $20bn profit after taxes in 2015.

The industry has long since accepted that its products are indeed harmful, but it remains an opponent of stricter regulation, sometimes using international courts to pursue claims against national governments.

Philip Morris International, for example, sued Australia over plain packaging by claiming the measures violated a bilateral trade agreement with Hong Kong. The company, which is the world’s largest international cigarette seller, has also sued Uruguay in an international court, challenging the introduction of health warnings covering 80 per cent of a packet of cigarettes.

Last year, Michael Bloomberg, owner of the Bloomberg financial media organisation, and Bill Gates, the founder of Microsoft, pledged $4m to a fund designed to help lower-income countries defend themselves against legal action from tobacco companies.

At the time, Mr Bloomberg said tobacco companies used legal action to “intimidate” poorer countries that may lack the funds or expertise to mount a defence.

Despite the efforts of the tobacco industry, regulation has largely advanced in many countries around the world. To a considerable extent, this is driven by an international treaty — a WHO initiative ratified by 180 countries — called the Framework Convention on Tobacco Control, or FCTC, which came into force in 2005.

That was a landmark moment, says Dr Ehsan Latif, director of tobacco control at the International Union Against Tuberculosis and Lung Disease, a health advocacy group.

In the years since, countries such as Brazil and Russia have made significant changes to smoking legislation. Two years ago, Russia prohibited smoking in restaurants, thus extending a public smoking ban enacted in 2013 along with new restrictions on advertising. The Russian government accompanied these measures with a series of tax increases.

Dr Latif, however, points to emerging market countries such as Indonesia as examples of the work that is yet to be done.

Studies put Indonesia’s smoking rate at about 60 per cent for men. Advertising is allowed on television, in newspapers and on billboards, according to the WHO.

Over the next two years, the country will be a crucial source of growth for tobacco companies. BNP Paribas estimates profits from cigarettes will grow faster in Indonesia over that period than in any other country in the world.

The Indonesian government in Jakarta has passed some tobacco control laws, says Dr Latif, but it has not signed up to the stricter international standards required by the FCTC. “Despite all efforts, Indonesia is not moving on that front,” he says. “They just don’t come to the party.”

The problem lies not just in persuading politicians to enact reforms, however, but also in ensuring proper implementation after that.

“If you take Asia, specifically Southeast Asia, there are countries that have adopted the policies but they have not been able to implement them because they don’t have public health infrastructure,” says Dr Latif. “Also the political will waxes and wanes.”

Another chief source of worry is Africa, which has comparatively low rates of smoking. While South Africa is known for having strong regulations on smoking, much of the rest of the continent has lighter rules.

Antismoking campaigners are keen to see restrictions introduced in advance of African incomes increasing and cigarette smoking becoming more popular. “It’s similar to any consumer product,” notes Dr Latif. “Once your purchasing [power] improves you can buy cigarettes.”

The challenge is as much cultural as it is regulatory and may extend beyond the reach of richer nations. “The developed countries pass the laws,” he adds, “and they think enough has been done.”


Health Minister Dr. Aaron Motsoaledi, is no stranger to tobacco legislation.

His stance on curbing the sale, advertising and use of cigarettes is well known, but now he wants to increase the Health Department’s scope to more than just the tobacco industry by going after ecigarettes.

In a recent interview with SABC on World No Tobacco Day, Motsoaledi said that electronic cigs should be treated the same way as normal tobacco cigarettes.

“We are looking at it very carefully. In the last framework (at the) Convention on Tobacco Control of the World Health Organisation held in South Korean recently, the decision was that we need to package ecigarettes as just any other type of cigarette,” he said.

Ecigarettes, instead of burning tobacco leaves, make use of liquids, which are heated by coils – much like a kettle. The resulting vapour that is produced by the evaporating liquid is inhaled by users. Think of it as inhaling the steam that is produced by a kettle – the mechanics are identical.

The Minister added that the ecig industry is trying to trick Health Departments across the world by making zero-nicotine ecigarette liquid (the liquid that gets vaporised).

“There is a trick here. Some ecigarettes have nicotine, which means they are just as bad as cigarettes – other don’t have nicotine,” he said. “Now that is a trick by the industry, saying that governments must only deal with those that have nicotine, which means I as a minister must now spend money to find out which ones do not have nicotine.”

“So the decision around the world from Ministers of Health is, ‘hey, do away with everything. It is not our job, it is the industry’s job’,” he added. “There is also a belief that those that don’t have nicotine, is introducing youngsters to smoking. When they start catching it, the next level is to go to real cigarettes.”

Motsoaledi’s comments about ecigarettes being a gateway to the smoking tobacco don’t seem to line up with current research co, which says that in 99% of cases, it is actually the other way around.

In the US, the Food and Drug Administration (FDA) recently set out Deeming Rights (guidelines) that ecigarettes should be classified as ‘tobacco products’.

The FDA also added that ecigarettes stores that produce their own liquid for use in ecigarettes are considered tobacco manufacturers, so anybody making their own juice is now a tobacco product manufacturer.

Among the other regulations set out by the FDA, this will have an impact on where people can use their ecigarettes if they fall into the same strict tobacco laws.

South Africa has historically been a leader in introducing tobacco laws, and if Motsoaledi turns to the FDA regulations, South Africa could follow suit in classifying ecigarettes as tobacco products.

Cigarette packs are being stripped of advertising around the world. But not in the US.

Cigarette packs have long served as portable advertising for tobacco companies, with smokers conveniently disseminating branding and imagery wherever they go.

Packaging has also long been a central target for health advocates in the global effort to get more people off deadly tobacco products.

This week, the World Health Organization called on countries everywhere to step up the war on tobacco advertising and promotion by introducing plain, or standardized, packaging of tobacco products.

“Plain packaging reduces the attractiveness of tobacco products,” said WHO Director-General Margaret Chan. “It kills the glamour, which is appropriate for a product that kills people.”

Before and after photos of cigarette packs from Australia, where plain packaging was introduced in 2012.

Before and after photos of cigarette packs from Australia, where plain packaging was introduced in 2012.

In 2012, Australia became the first country in the world to introduce the measure. Tobacco companies there are now restricted in their use of logos, colors, and brand images, and instead have to use a standard (unsavory green) color and plain font. The boxes also prominently feature warnings about the harms of smoking, including nasty images that show what cigarettes can do to the body.

Others countries — France, the United Kingdom, and Ireland — are now following Australia’s lead, implementing plain packaging regulations of their own. Norway, Hungary, Slovenia, Sweden, Finland, Canada, New Zealand, Singapore, Belgium, and South Africa are all formally considering similar measures.

Notably, the United States isn’t even close to getting plain packaging on cigarettes anytime soon. We’ll get to why we’re lagging on this front, and why we really shouldn’t be, below. But first, here’s why plain packaging makes sense for public health.

Plain packaging works — but not necessarily by helping people quit

More before and after photos of cigarette packs from Australia, where plain packaging was introduced in 2012.

More before and after photos of cigarette packs from Australia, where plain packaging was introduced in 2012.

Smoking is the leading cause of preventable death globally, killing about 6 million people every year. Tobacco marketing is considered a massive driver of cigarette use — which is why the industry shells out tens of billions every year pushing its products to consumers. Cigarette companies also mislead consumers about the relative harms of certain types of cigarettes through the use of colors (light colors appear to imply a product is safer) and language (think “light,” “organic,” or “low tar”).

To counteract those marketing efforts, governments started requiring gruesome pictures of the health effects of cigarettes on packs in 2000. (These have more of an impact than text-only warnings.)

Plain packaging came next, with Australia introducing the world’s first regulations in 2012. According to the Framework Convention on Tobacco Control, a global health treaty aimed at reducing the use of tobacco products, plain cigarette packs have three public health benefits: They make tobacco products less appealing, they make health warnings more prominent, and they limit tobacco companies’ use of design to mislead consumers.

There’s good evidence to back this up. A number of systematic reviews of the research have come to pretty consistent conclusions that plain packaging works. As this 2015 review summed up:

Studies deploying a range of methodologies, including observational and experimental research, consistently show that plain packaging can reduce the appeal of cigarettes, decrease the power of the cigarette pack as a marketing vehicle, increase attention to the health warning labels, and impact smoking-related attitudes and cognition.

There’s also strong evidence from Australia, now four years into its plain packaging effort, that the measure has had an impact on smoking habits. The government commissioned a review of the impact of the packaging changes and found that smoking rates fell an additional 0.55 percentage points between December 2012 and September 2015 — a drop that it attributed to the packaging changes only (and not the other anti-tobacco policies the country implemented around that time).

“This equates to more than 108,000 people quitting, not relapsing or not starting to smoke during that period,” the WHO pointed out. That’s a big public health win.

But as University of Waterloo tobacco control policy expert David Hammond noted, these policies aren’t necessarily aimed at making people quit. They’re more about prevention: reducing the number of people who start smoking and protecting young people from tobacco marketing. “The expectation is that the benefit will accrue and grow over time as children grow up without the positive brand imagery on packages,” Hammond said.

Either way, they seem to be helping. And according to University of Stirling tobacco packaging researcher Crawford Moodie, that should be no surprise: “The findings [on the benefits of plain packaging] are also consistent with idea that packaging is an important vehicle for marketing, as is clear from the tobacco industry’s own internal documents.” Indeed, tobacco industry communications were made public through legislation and shed light on how the industry hooks consumers.

“If you look at what tobacco companies say,” Moodie added, “it paints quite a powerful image of the packaging.”

When countries try to restrict packaging, tobacco companies fight back

Unsurprisingly, just about every time a country even so much suggests it’s going to introduce plain packaging on cigarettes, tobacco companies threaten lawsuits. Typically, they dispute the packaging restrictions on the grounds that they violate international trade and trademark laws and their right to free speech.

Governments have so far managed to win most of these cases.

The Australian government has faced three separate challenges and won two (with a third decision still pending). In one particularly bold effort, Philip Morris International transferred ownership of its Australian operation to Hong Kong in order to fight the plain packaging mandate there by exploiting the provisions in a bilateral trade agreement between Hong Kong and Australia. It lost.

Last week, tobacco companies in the UK tried to stop plain packaging efforts there, but also lost. The ruling said plain packaging may infringe a company’s right to free speech on the package — but that that’s justified on health grounds in the public interest.

“[These lawsuits] are meant to be a deterrent to other jurisdictions,” said Hammond. “They require a huge amount of resources to fight.”

The US hasn’t updated the health warnings on packs in 31 years

Compared with most other Western nations, the US has been sluggish to rein in the advertising on cigarette packs. Efforts to update warnings have mostly stalled or failed, and as a result US cigarette packs haven’t changed much since the 1980s.

Why? Typically the First Amendment argument is invoked: Protections on free speech here are so strong that public health officials don’t stand a chance, the thinking goes.

But according to Hammond, “Protection of free speech in the US is not unique.” The UK has it, too, but also managed to implement plain packaging measures after tobacco companies (including British American Tobacco, Philip Morris International, Japan Tobacco International, and Imperial Brands) challenged the law, taking the case up to the UK High Court. (The court rejected the challenge.)

According to Kenneth Michael Cummings, co-leader of the Medical University of South Carolina’s tobacco research program, in the US “it’s all about the lobbying.” He added: “We have the best Congress money can buy.”

The powerful tobacco lobby in the US has managed to delay federal regulation of the industry for decades. The Food and Drug Administration only gained authority over the tobacco industry in 2009 with the Family Smoking Prevention and Tobacco Control Act.


What’s more, there are 180 countries that have ratified the UN’s Framework Convention on Tobacco Control, which commits countries to require graphic warnings on packs and other anti-smoking regulations. The US isn’t one of them, which “means the US isn’t obligated to do what other countries have done,” Cummings said.

Dozens of countries in Latin America and Asia have already implemented five rounds of pictorial health warnings on packaging over the past decade, but packaging in the US hasn’t changed much since 1985. A text-only surgeon’s general warning was introduced in 1966, but it hasn’t been updated in 31 years.

“The lack of movement on packaging in the US is consistent with a lot of other areas [in tobacco control],” Hammond said. “The US probably falls below third-world countries in terms of some of the tobacco control policies related to labeling.”

FDA spokesperson Michael Felberbaum told Vox that the agency has added some packaging restrictions on tobacco products in recent years, including prohibiting the use of descriptors such as “light,” “low,” or “mild.” In 2016, FDA also began asking companies to warn smokers that “nicotine is an addictive chemical” — but that statement won’t appear on all packaging until mid-2018.

But attempts to go any further have so far flopped. In 2011, the FDA published a rule that required companies to use new text and graphic images on packs — but that was challenged in court by several tobacco companies. The FDA is now working to come up with alternatives that are consistent with what the tobacco statute says and the court has ruled. Plain packaging, however, is not yet part of that conversation.

The next frontier: uglier packaging inserts and cigarettes

The future: cigarettes that carry warnings on them, plus inserts about quitting.

The future: cigarettes that carry warnings on them, plus inserts about quitting.

In the future, public health researchers around the world are already thinking about how to make more elements of a cigarette package unappealing — including the interior and the cigarettes themselves.

Moodie discussed the idea of inserts in tobacco packages that contain information about quitting and the benefits of doing so, and the possibility of uglier cigarettes with unattractive designs and health warnings written right on them.

He’s not holding his breath for all those changes. The first visual warnings were introduced on cigarette packs in Canada in 2000. It’s taken nearly 20 years to get widespread adoption. If plain packaging follows that same timeline, it’ll be about 2030 by the time a significant number of countries introduce regulations. Considering we’ve known for about half a century that cigarettes can kill people, that’s (darkly) comically slow. And in the US, even more so.

E-cigarettes and Lung Health

On May 5, the Food and Drug Administration (FDA) announced it will be extending its authority to include e-cigarettes and other tobacco products. Starting in August 2016, FDA will begin to apply and enforce key provisions of the Family Smoking Prevention and Tobacco Control Act as it relates to the sales, marketing and manufacturing of e-cigarettes.

The American Lung Association had long called for FDA to bring e-cigarettes and other unregulated tobacco products under its authority. This action was especially important given the rapid rise in youth use of e-cigarettes in the U.S. over the past several years.

How Will FDA Oversee E-cigarettes?

A 2010 ruling from a federal court in a case filed by an e-cigarette manufacturer against the FDA determined that e-cigarettes which do not make therapeutic claims will be regulated as tobacco products.

If a manufacturer does make a therapeutic claim (such as that an e-cigarette can help you quit smoking), then the manufacturer must first prove through a series of clinical trials that their product is safe and effective.

What Are E-cigarettes?

Electronic cigarettes, or e-cigarettes, include e-pens, e-pipes, e-hookah, and e-cigars are known collectively as ENDS – electronic nicotine delivery systems. According to the FDA, e-cigarettes are devices that allow users to inhale an aerosol (vapor) containing nicotine or other substances.

Unlike traditional cigarettes, e-cigarettes are generally battery-operated and use a heating element to heat e-liquid from a refillable cartridge, releasing a chemical-filled aerosol.

What Are in E-cigarettes?

The main component of e-cigarettes is the e-liquid contained in cartridges. To create an e-liquid, nicotine is extracted from tobacco and mixed with a base (usually propylene glycol), and may also include flavorings, colorings and other chemicals.

Following the 2016 announcement allowing FDA oversight of tobacco products, e-cigarette manufacturers must register with FDA by August 8, 2016, and then will have two additional years to submit an application to remain in the marketplace. Until that time, the nearly 500 brands and 7,700 flavors of e-cigarettes will remain on the market – before FDA is able to fully evaluate them. Until FDA’s evaluation is done, there are very few ways for anyone other than the manufacturers to know what chemicals are contained in e-liquids, or how e-cigarette use might affect health, whether in the short term or in the long run.

Initial studies show that e-cigarettes contain nicotine and also may add in other harmful chemicals, including carcinogens and lung irritants.


Nicotine is an addictive substance, and almost all e-cigarettes contain nicotine. Even some products that claim not to have any nicotine in them may still contain it. For instance, initial FDA lab tests conducted in 2009 found that cartridges labeled as nicotine-free had traceable levels of nicotine. A 2014 study found little consistency in the amount of nicotine delivered by e-cigarettes of the same brand and strength.1 Similarly, another 2014 study found that the amount of nicotine in e-liquid refills is often substantially different from the amount listed on the package.2 Experienced users learn how to use e-cigarettes in a way that increases their exposure to nicotine. Newer e-cigarette devices, especially “tank” styles, with higher voltage also deliver a greater concentration of nicotine. This matters because the more nicotine used, the greater the potential for addiction.

Nicotine is not safe. The U.S. Surgeon General has found exposure to nicotine during pregnancy harms the developing fetus, and causes lasting consequences for the developing brain and lung function in newborns. Nicotine exposure also affects maternal and fetal health during pregnancy, and can result in low birth weights, preterm delivery and stillbirth.

Nicotine also has a negative impact on adolescent brain development. Human brain development continues far longer than was previously realized, and nicotine use during adolescence and young adulthood has been associated with lasting cognitive and behavioral impairments, including effects on working memory and attention.3

Other chemicals

We don’t presently know what is in e-cigarettes. However, in initial lab tests conducted in 2009 the FDA found detectable levels of toxic cancer-causing chemicals, including an ingredient used in anti-freeze, in two leading brands of e-cigarettes and 18 various cartridges. A review of studies found that levels of toxins in e-cigarette aerosol varied considerably within and between brands. A 2014 study found that aerosol from e-cigarettes with a higher voltage level contains more formaldehyde, another carcinogen with the potential to cause cancer. The findings are alarming, and underscores why the American Lung Association called so urgently for FDA oversight of these products.

Flavors in e-cigarettes are also a cause for concern. Not only are flavors used to target kids, but they may be harmful on their own. E-cigarette and flavor manufacturers and marketers may suggest that the flavor ingredients used in e-cigarettes are safe because they have FEMA GRASTM status for use in food, but such statements are false and misleading. The reality is that FEMA GRASTM status only applies to food, meaning it’s safe to eat, and does not apply to inhaling through e-cigarettes.

Diacetyl, a buttery flavored chemical often added to food products such as popcorn, caramel, and dairy products, has also been found in some e-cigarettes with flavors. Diacetyl can cause a serious and irreversible lung disease commonly known as “popcorn lung.”4

Poisoning concern

Aside from concerns about e-cigarette use and emissions alone, data released by the Centers for Disease Control and Prevention (CDC) shows that calls to the nation’s poison centers for e-cigarette exposure poisonings are rapidly increasing. One study found that while most calls involving e-cigarette liquid poisoning came from accidental ingestion of the e-cigarette or its liquid, about one-sixth of the calls related to someone inhaling these items. Exposure through the eye and the skin were also reported.

Large doses of nicotine have a potential for poisoning, with symptoms beginning with nausea and vomiting in cases of acute toxicity and progressing to seizures and respiratory depression in cases of severe nicotine poisoning. This is particularly true in children as calls to poison control centers have increased nationwide. Tragically, one child died from acute e-cigarette poisoning in 2014, attributed to the ingestion of liquid nicotine from an e-cigarette.

Secondhand Emissions from E-cigarettes?

As public spaces increasingly become smokefree, anecdotal reports show some people are attempting to use e-cigarettes indoors and in public spaces which are smokefree, like bars, restaurants and even public transit.

While e-cigarettes do not contain smoke, they do expose others to secondhand emissions. Little is known about these emissions or the potential harm they can cause. Two studies have found formaldehyde, benzene and tobacco-specific nitrosamines (all carcinogens) coming from those secondhand emissions. Other studies have shown that chemicals in the vapor contain formaldehyde, acetaldehyde and other potential toxins. There is no evidence that shows e-cigarettes emissions (secondhand aerosol) are safe for non-users to inhale.

The American Lung Association supports prohibiting the use of e‐cigarettes in worksites and public places, and including e-cigarettes under smokefree laws with other tobacco products. Currently, nine states and hundreds of communities have prohibited e-cigarette use in the same places where smoking is already prohibited.

Can E-cigarettes Help Someone Quit Smoking?

Many e-cigarette companies market their product as a tool to help smokers quit. However, the FDA’s Center for Drug Evaluation and Research has not approved any e-cigarette as a safe or effective method to help smokers quit.

Instead of quitting, many e-cigarette users are continuing to use e-cigarettes while still using conventional cigarettes. In 2013, 76.8 percent of the people who recently used e-cigarettes also currently smoked conventional cigarettes. The U.S. Surgeon General has found that even smoking a few cigarettes a day is dangerous to your health.

The U.S. Public Health Service has found that the seven therapies approved by the U.S. Food and Drug Administration in combination with individual, group or phone cessation counseling are the most effective way to help smokers quit. Until and unless the FDA approves a specific electronic nicotine delivery system or e-cigarette as safe and effective for use as a tobacco cessation aid, the American Lung Association does not support their use for cessation or any direct or implied claims that e-cigarettes help smokers quit.

Youth and E-cigarettes

Youth are using e-cigarettes at increasing and alarming rates. Between 2014 and 2015, CDC studies found e-cigarette use among high school students increased by 19 percent, with more teens now using e-cigarettes than cigarettes.

The tobacco industry aggressively markets e-cigarettes to youth, glamorizing e-cigarette use in advertisements and offering e-cigarettes in candy flavors like bubble gum and gummy bears. Kids can also easily buy e-cigarettes online, according to a March 2015 study published in JAMA Pediatrics. Learn more about youth e-cigarette use. Basic FDA oversight, which would include youth access restrictions, is needed to protect kids from becoming the next generation hooked on nicotine.

Bottom Line

E-cigarettes are a tobacco product. The American Lung Association remains concerned about their impact on the public health, as they are now the most commonly used tobacco product by youth. As FDA begins its oversight of these products, we will learn more about them and more safeguards will be put in place to protect the public health.

Smokers who wish to quit can learn more about ways that have been proven safe and effective in helping smokers quit at

Learn more: Read the American Lung Association’s statement on e-cigarettes.

Updated: June 2, 2016


Goniewicz ML, Hajek P, McRobbie H. Nicotine Content of Electronic Cigarettes, its Release in Vapour and its Consistency Across Batches: Regulatory Implications. Addiction. 2014;109:500-7.
Cameron JM, Howell DN, White JR, Andrenyak DM, Layton ME, Roll JM. Variable and Potentially Fatal Amounts of Nicotine in E-Cigarette Nicotine Solutions. Tobbaco Control. 2014;23:77-8.
U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. 2014.
Farsalinos KE, Kistler KA, Gillman G, Voudris V. Evaluation of electronic cigarette liquids and aerosol for the presence of selected inhalation toxins. Nicotine Tob Res, 2014; 17:168-74.
Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students – United States, 2011–2014. Morbidity and Mortality Weekly Report April 17, 2015; 64(14):381-5

Monitoring tobacco packaging and labelling in South-East Asia

A new index is helping governments in South-East Asia strengthen implementation of tobacco packaging and labelling in their countries.

Key findings from the index:

  • All 10 ASEAN countries apply pictorial health warnings (PHWs).
  • Thailand leads with the largest PHWs.
  • Legislated health warnings are applied to all forms of tobacco packaging among the ASEAN countries.
  • All ASEAN countries ban adhesive labels, stickers, cases, covers, sleeves, wrapping and promotional inserts and onserts on tobacco products that can obscure, obliterate or undermine health warnings.
  • Seven countries gave less than 10 months to the tobacco industry to comply with pictorial warnings.
  • Enforcement authorities in seven ASEAN countries possess sufficient powers to order violators to recall non-compliant tobacco products.
  • All ASEAN countries indicated that their health warning law or regulation needed to be reviewed and updated periodically.

Say Why To Drugs: the smoke and mirrors of tobacco cigarettes

In this series, I’ll be investigating different drugs, busting some myths and explaining potential harms and benefits. This week it’s the turn of tobacco

What’s the appeal?
Tobacco, the dried leaf that’s smoked in cigarettes, cigars and pipes, and taken in various other forms such as snus and chewing tobacco, has been used as a recreational drug for hundreds, if not thousands of years. Cigarettes as a method for smoking became popular during World War one, when they were included as part of soldiers’ ration packs. People who smoke report that it relives stress, and can make them feel calmer and more relaxed. But is this really the case? Two in three smokers will have started smoking before the age of 18, and smoking is illegal in this age group, in the UK and many other countries around the world. The percentage of current smokers who want to quit is similarly high (around 2 in 3 current smokers report wanting to quit).

Short term effects
While there’s no real intoxication effect of cigarettes, if a person is not used to nicotine, a cigarette can make them feel sick or dizzy. Smoking a cigarette raises your heart rate. If a person is a regular smoker and addicted to nicotine, then smoking a cigarette can bring a person out of withdrawal. Nicotine withdrawal is characterised by feelings of anxiety, irritability, headaches and difficulty concentrating. It could be that the reason smokers report that cigarettes lower their anxiety and stress is because of the alleviation of these withdrawal effects – indeed, this seems likely, as long term use of cigarettes is associated with higher levels of depression and anxiety.

Long-term effects
The health impacts of cigarettes have been known for well over half a century. Cigarettes are responsible for the premature deaths of 2 in 3 users, according to recent figures from the UK and the USA. Smoking causes lung cancer, and at least 13 other types of cancer, to a varying degree. Cancer Research UK estimate that smoking causes a quarter of all cancer deaths in the UK, and nearly 1 in 5 cancer cases. Smoking also increases the risk of heart disease and lung disease aside from cancer.

There has been some suggestion that smoking, or nicotine in particular, might be beneficial for Parkinson’s disease. Indeed, Parkinsons UK have funded research looking in to this. However, as yet the evidence is thin on the ground, and there’s some reason to believe that this seemingly positive association might be a statistical artefact. Given that smoking kills so many people who do it, the smokers who survive long enough to be at risk of Parkinson’s disease might be an unusually hardy bunch, so it could be this rather than the nicotine that’s protective against Parkinson’s. Elderly smokers represent a really interesting population to research for this reason, if we can identify why they don’t succumb to smoking related illnesses, this might be extremely useful for designing treatments for others.

Myth busting
Nicotine is extremely dangerous: No, while nicotine is the addictive substance in cigarettes, it’s not the really harmful part of them. The process of burning tobacco releases carbon monoxide, hydrogen cyanide, at least 70 known carcinogens, and a variety of other chemicals. Nicotine is addictive, but specifically in cigarettes rather than in other forms, as tobacco’s acidity in cigarettes differs from cigars and chewing tobacco, meaning that nicotine is absorbed through the lungs when smoking cigarettes, giving a much more immediate hit. Cigars, inhalators, nicotine gum and patches all have a slower effect due to the nicotine being absorbed through the mouth or skin, and therefore taking longer to reach the brain.

Shisha is less harmful than cigarettes: A lot of people assume that shisha is less harmful than smoking cigarettes, because the smoke is cooler, and because of the flavouring, some people assume that shisha doesn’t contain tobacco. However, most commonly shisha will contain tobacco, and although the smoke is cooler, very little filtering of the smoke occurs as it passes through the water, and the current evidence suggests its unlikely to be less harmful than cigarattes. However, given different smoking patterns when using shisha compared to cigarettes, direct comparisons are hard. Although shisha sessions often last a lot longer, they are undertaken much less frequently. And far less research has been conducted on the effects of shisha, as compared to cigarettes. Even so, it seems that shisha is not as safe as a lot of people seem to assume it is.

Menthol cigarettes are safer/menthol cigarettes are more harmful: There is disagreement even among the myths surrounding menthol cigarettes. Again, there’s been less research conducted on menthol cigarettes compared to regular cigarettes, but there’s no evidence to suggest they’re any more or less harmful – it seems likely that they’re just as harmful as regular tobacco.

Roll-ups and natural tobacco are less harmful: It’s a common belief that rolling tobacco contains less of the harmful chemicals and components than machine made cigarettes. This is a myth. Some studies have found that rolling tobacco actually contains more additives than factory made cigarettes, and one animal study suggested that rolling tobacco was more addictive, although this was a small study.

Light or low tar cigarettes are less harmful: You may have noticed that there’s no such thing as Marlboro lights any more. Tobacco companies are no longer allowed to market cigarettes as ‘light’, since light cigarettes were no less harmful than regular cigarettes. And this was due to the difference between humans and machines. Light cigarettes were created by altering the filter – more holes were added to it, with the idea being that smoke would escape before being inhaled, so less harmful particles would be breathed in. This was tested using machines that ‘smoked’, and lo and behold, this was the case. The machines ‘inhaled’ lower levels of smoke. But humans aren’t machines, and altered their smoking patterns, squeezing at the filters and dragging more deeply on the cigarettes, meaning any benefit of the altered filters was lost.

Cutting down smoking will reduce the levels of harm from smoking: It seems hard to believe that this isn’t the case, but cutting down the number of cigarettes you smoke doesn’t necessarily reduce the risk of smoking-related harm. This is related to the myth above – if a person is used to getting a certain amount of nicotine in a day, then if they smoke fewer cigarettes, they’re likely to draw more deeply, take more puffs, and hold the smoke in their lungs longer for the cigarettes they do smoke. Psychologically, cutting down is a great first step in the quit process, but in terms of harm reduction, quitting is really the only way.

What do we still not know?
You might think that we know all there it to know about cigarettes and tobacco. We’ve known for more than half a century that smoking causes lung cancer, and the physical effects of smoking are fairly well understood. But there is still a lot that we don’t know. For example, why do some people find it really easy to quit smoking, while others really struggle? There’s evidence that smoking behavior is partly genetic. Genotype predicts how heavily a smoker will smoke, and can affect it up to the level of a couple of cigarettes extra per day. This might go some way to explaining why it’s easier for some to give up than others, and could even represent a method to work out how to help a person to quit. If your addiction is stronger, maybe you’ll need pharmacotherapy rather than trying to quit cold turkey, for example.

The other emerging area of research that I’m really interested in is trying to understand why smoking rates are so much higher in populations with mental health difficulties. We understand the physical effects of tobacco so well, but we’re much less sure about why these associations come about.

These articles are companion pieces to my Say Why To Drugs podcast, which can be listened to here.

Previous articles in the Say Why to Drugs series can be found here: cannabis.

This piece was corrected on 2 June 2016 to clarify that the statement ‘nicotine is extremely dangerous’ is a myth.