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September 6th, 2016:

Anti-tobacco law to be upgraded with harsher punishments, fines

One decade after a law to control tobacco use went into effect, the government is finally pledging to give teeth to the legislation. Violators could face increased fines and even prison time, health officials warn.

Dr Thuzar Chit Tin, director of the Ministry of Health and Sport, said the 2006 Control of Smoking and Consumption of Tobacco Products Law is in the process of being updated, with fines raised to reflect the current economy and act as a bigger disincentive.

Under the existing law, advertising tobacco products, distributing cigars, cigarettes or other tobacco products free of charge, sponsoring sports and other exhibitions, or publicising tobacco by any means is subject to a fine ranging from K20,000 to K50,000 for the first offence, rising to a maximum of K200,000 or two years in prison for subsequent offences. Penalties also apply to anyone who tries to obstruct or assault officials trying to prevent smoking in a no-smoking zone.

“Amendments will be made to the law to upgrade the punishments” and bring them into conformity with current conditions, said Dr Thuzar Chit Tin on September 1.

Myanmar launched a tobacco-free program in 1980, after introducing its first anti-smoking legislation in 1959 with an act that banned smoking in theatres.

Though the consumption of cigarettes and tobacco products decreased in 2007 after the control of smoking law came into effect, usage subsequently increased, apparently in part because of lax enforcement, particularly with regard to the ban on selling cigarettes within 100 feet (30.5 metres) of a school, or selling single cigarettes. Tobacco companies were among the first to quickly enter the country after the government began relaxing import restrictions.

According to a 2014 survey, the rate of tobacco use in Myanmar is 26.1 percent of the population, including 43.8pc of men and 8.4pc of women. About 80pc of smokers use tobacco every day. About 7pc of students smoke, and 17pc use cigars or other forms of tobacco.

The rate of betel use is higher, with 43pc of the population consuming betel, including 62pc of men and 24.1pc of women.

One of the problems in countering consumption, Dr Thuzar Chit Tin said, is that tobacco, betel and pickled tea leaves are considered traditional leisure activities, and their use seems to be rising. “We need to educate the public about the dangers of smoking,” she said.

However, she said, the tobacco industry is very powerful and influential compared to the resources available to the government. “The tobacco industry influences policymakers and the media. They have the financial resources to ensure that what the industry says gets better media coverage than the information we provide.”

She added that the updated law could also apply some of the tax derived from tobacco products to the health sector and to public education drives intended to reduce smoking.

In 2010 the government doubled the tax on cigarettes to 100 percent, while taxes on other tobacco products, including cheroots, were raised to 50pc in 2012. Additionally, shops are required to charge a 5pc sales tax. But according to the Internal Revenue Department, most cigarette producers do not pay the tax because of a lack of enforcement.

But measures to scale up the warning labels on tobacco products have gained traction. In 2014, the Myanmar Cigarette and Tobacco Products Consumption Controlling Central Committee added picture and text health on packaging and branding tobacco products. In June, the Ministry of Health announced that warning labels must appear on all brands of tobacco products in Myanmar from September.

The ministry released a notification in February calling for the implementation of the 2006 law. But the six-month period that was to have elapsed before enforcement began has been extended a further six months following appeals from the industry. The law is now expected to come fully into force in March 2017.

Translation by Thiri Min Htun

St. Louis County could raise minimum age to buy tobacco

ST. LOUIS, MO (KTVI)-Soon it may be harder for those under 21 to purchase tobacco products and e-cigarettes. The St. Louis County council could pass a bill at tonight’s meeting that raises the age to buy tobacco products from 18 to 21.

Opposition from the e-cigarette industry says vaping products should not be included with the tobacco. But a council member says the FDA ruled e-cigarettes can be regulated along with tobacco products.

If the bill is passed tonight, it would take effect at the end of the year.

Health costs of smoking may be higher than tobacco profit

Quitting smoking is hard as cigarettes contain nicotine, an addictive substance in tobacco that fuels cravings. After smoking, the brain becomes dependent on the nicotine and has thus rewired itself.

Because of this physical dependency, if a person stops smoking for a period of time, they will start experiencing symptoms of withdrawal. This is the brain and body adjusting to no longer having nicotine in the system.

But quitting smoking in a country like Indonesia, where 67 percent of men smoke, poses a different kind of challenge altogether.

After smokers overcome their withdrawal symptoms, such as anger and anxiety, they still have to face the last stage of overcoming nicotine addiction, which is reinforcement.

“The reinforcement challenges in Indonesia are very strong. People who have quit smoking will start smoking again once they see their neighbors smoking and smell the smoke. They might also see cigarette ads and start smoking again,” Widyastuti Soerojo of the Public Health Scholars Association (IAKMI) told The Jakarta Post.

This has led to an extremely low quit ratio for smokers in Indonesia. According to data from the World Health Organization (WHO), the quitting ratio for men in Indonesia is only 9 percent, while it is 23.2 percent in women.

Lioni Hendrawaty, a 30-year-old NGO worker, is an example of someone who finds that the temptation to smoke again after quitting is too much to resist.

She has been a smoker for 14 years. Throughout that time, she had tried repeatedly to quit smoking.

She said that she noticed her breathes getting shorter and so she was afraid that her habit would eventually kill her.

Lioni was diagnosed in 2014 with hypothyroid, a common disorder in which the thyroid gland does not produce enough thyroid hormone. “Since I was diagnosed, every time I smoke, my heart beats faster. It’s uncomfortable,” she told the Post.

Consequently, she was told by her doctor to stop smoking as her smoking habit would only exacerbate her illness.

But it turns out that being ill is not enough for someone like Lioni to stop smoking.

“Actually I had succeeded in reducing my cigarette consumption to once a day. At the most, I smoke three cigarettes in one day,” she said.

Therefore, it is important to make smoking not normal and not cool as the stakes are too high for Indonesia.

Though the government often argues that the tobacco industry brings much-needed revenue to the country, with it targeting to collect Rp 148.86 trillion from tobacco excise this year, the economic loss from tobacco consumption is actually much greater.

In 2013, the total loss due to tobacco consumption hit Rp 378.75 trillion, according to the Health Ministry, resulting from lost productivity due to illness, disability and premature death in youth and medical expenses.

Indonesia’s economy is also expected to lose Rp 59,580 trillion (US$4.5 trillion) by 2030 from tobacco-related diseases.

The University of Indonesia’s demographic institute associate director, Abdillah Ahsan, said Indonesians are having the hardest time to quit smoking because smoking is already considered normal in the country.

Smokers who want to quit will be constantly seduced by everyone who smokes around them as well as by pervasive cigarette advertisements.

“Access to cigarettes is very easy. If I live in a housing complex, I will find a small stall selling cigarettes just a few houses from me. It’s also easy for children to buy cigarettes. If they step out of their schools, they will find a warung. Above the warung will be a banner advertising cigarettes,” Abdillah said.

Furthermore, public officials are often shown to be smoking in public spaces, such as lawmakers around the parliament building.

E-cigarette adverts could encourage children to take up tobacco, warn Cambridge scientists

Adverts for e-cigarettes may encourage more children to experiment with tobacco smoking, Cambridge scientists have warned.

A team from Cambridge University found children exposed to adverts for ‘vaping’ are more likely to believe occasional smoking poses no risk to their health.

Working with colleagues from the University of North Carolina, they recruited more than 400 English children aged 11 to 16, who have never smoked or vaped before.

One group was shown adverts depicting e-cigarettes as glamorous, a second was shown adverts that portrayed them as healthy, and a third control group was shown no adverts.

Those shown the adverts were no more or no less likely than the control group to perceive tobacco smoking as appealing, and all three groups understood smoking more than 10 cigarettes a day was harmful.

However, the groups exposed to the adverts, both healthy and glamorous, were less likely to believe smoking one or two tobacco cigarettes occasionally was harmful.

There is concern the increasing exposure of children to e-cigarette adverts could be contributing to high rates of experimentation.

Dr Milica Vasiljevic from Cambridge’s from the Department of Public Health and Primary Care, said: “This is worrying, as we know even occasional tobacco smoking is bad for your health, and young people who smoke occasionally believe they are somehow immune to its effects and do not feel the need to quit.”

The group shown the ‘glamorous’ adverts also believed e-cigarette vaping to be more prevalent than the other two groups did.

Researchers also highlighted a 2014 study that showed more children aged 11 to 15 experimented with e-cigarettes than tobacco (22 per cent compared with 18 per cent).

Professor Theresa Marteau, director of Cambridge’s Behaviour and Health Research Unit, said: “E-cigarette marketing across Europe is regulated under the new EU Tobacco Products Directive, which came into effect on May 20 this year.

“The directive limits the exposure of children to TV and newspaper e-cigarette adverts.

“However, it does not cover advertising in the form of posters, leaflets, and adverts at point of sale, nor does it cover the content of marketing materials depicting e-cigarettes as glamorous or healthy.

“The findings from our study suggest these omissions could present a threat to the health of children.”

The research, funded by the Department of Health, was published in the journal Tobacco Control.

Proud to be a dangerous woman – Prof Judith Mackay

Professor Judith Mackay is a member of the GHA and is a Hong-Kong based tobacco control researcher and activist.

She is Senior Advisor, Vital Strategies/Bloomberg Initiative to Reduce Tobacco Use; Director of the Asian Consultancy on Tobacco Control; and Senior Policy Advisor to World Health Organisation.

She has authored 12 atlases on health topics. In addition to many international awards, ranging from the WHO Commemorative Medal and the TIME 100 award to the first BMJ Group Lifetime Achievement Award, she has been identified by the tobacco industry as one of the three most dangerous people in the world.

She recently contributed to the Dangerous Women project, an initiative of the Institute for Advanced Studies in the Humanities at the University, which analyses the dynamics, conflicts, identities and power relations with which women live today.

Read Judith’s contribution here …

“It wasn’t my intention to be a dangerous woman or to find myself in danger, simply by being committed to gender equality and better health.

There was nothing in my medical degree course at the University of Edinburgh in the 1960s to predict that I would be labelled by the tobacco industry as one of the three most dangerous people in the world, or that I would need to be offered 24-hour police protection by the Hong Kong government.

Perhaps the first hint of danger in my life was when I arrived in Hong Kong in 1967 at the peak of the Chinese Cultural Revolution – which spilled over into Hong Kong – with Communist schools and banks barricaded and manufacturing bombs, and big character posters saying ‘Down with imperialists’ and ‘British go home.’ Street riots rocked the colony, bringing with them waves of bombings, looting and arson attacks. British rule became precarious, but held – only just – when Chinese Premier Chou Enlai reined in the HK Red Guards.

A Dangerous Feminist

I became a committed feminist at about the same time (and still am today, 50 years on), and this did not lie easily in colonial Hong Kong, where even senior government figures and judges would joke about rape. People viewed me as dangerous and subversive (and wrote many letters to the press saying just that). This could spill into physical abuse, such as when a friend’s husband twisted a necklace (engraved with the sign for women) round my neck, lifted me off the floor and snarled that “Women will never be the equal of men as they are not as strong,” while I dangled helplessly in the air, powerless. I determined never to let that happen to me again. Even more bizarrely, another woman friend only recently told me that the husband of a mutual friend had tried to rape her, saying ‘This is for Judith Mackay,’ as he perceived his wife was coming under my feminist influence.

A Dangerous Subversive in The Medical Profession

In the 1980’s, I earned the fury of my own medical profession by writing a health series in the South China Morning Post, Hong Kong’s leading English language newspaper. The article broke the then-traditional power mode of doctor-patient relationships by encouraging women, in particular, to keep their own personal health record, and participate in their own health care decisions. ‘When your doctor tells you…’ became ‘When you and your doctor decide…’ A senior gynaecologist stormed up to the hospital where I worked, found me in Medical Outpatients, pinned me against a wall, and said ‘This newspaper series has to stop or you will be in trouble.’ I said that this sounded like a threat, and he said ‘You have powerful enemies in the medical profession, and had better watch out.’ He went on to say that only that morning he was inserting a copper intra-uterine device in a patient, who had meekly asked ‘Is this a copper coil?’ and he was furious – asking her ‘Have you been reading Dr. Mackay’s column in the SCMP?’ – the trigger to his visit.

A Danger to Big Tobacco

I’ve faced the greatest danger since moving from clinical to preventive medicine. There were three main reasons for making the shift from hospital medicine to public health. First, during my work as a physician in the 1970s and 1980s, I came increasingly to feel that clinical work was like ‘a band-aid.’ In fact, we had a maxim on our male medical ward that we never admitted a non-smoker, our wards being full of people with end-stage tobacco illnesses, often too late to prevent morbidity and mortality.

Second was the realisation that although women’s health in those days was defined as reproductive health, tobacco was killing far more women than were dying from birth control – and the tobacco industry was actively recruiting women with promises of beauty, slimness, popularity and emancipation.

What finally galvanised my determination to combat tobacco use was the response to a piece I wrote on tobacco as part of my series on women’s health in the South China Morning Post. One of the British transnational cigarette companies published a booklet labelling me as ‘entirely unrepresentative and unaccountable.’ In contrast, the self-promotional booklet claimed ‘the tobacco industry comprises identifiable, legal, accountable, commercial organizations.’ This booklet, denying the health evidence (‘it has not been proven that these illnesses are actually caused by smoking’) and claiming to be an ‘important source of reliable information’ on smoking, so enraged me that from that moment on I worked on tobacco control, abandoning curative hospital medicine in 1984.

Why was my job so dangerous? It was partly location. The tobacco industry thought they could gallop their Marlboro cowboy into Asia, and it was theirs for the taking. They even said ‘What do we want? We want Asia,’ with the dream of converting the 60% of men who smoked local cigarettes to switch to international brands, and the second dream of persuading Asian women to start smoking. Given the numbers concerned, it would not have mattered if every smoker in the UK had stopped smoking the next day, if they could have captured the massive Asian markets.

There was no career structure and no pay, but I set about thwarting their goals. I was in touch with colleagues in the UK and elsewhere who were unstinting in their assistance, but it was a lonely job in Asia in the 1980s.

This brought me into conflict with one of the world’s most wealthy and powerful industries – and its supporters. I’m frequently subjected to verbal abuse and have been described over the years as sanctimonious, dogmatic, pontificating, meddlesome, heretic, puritanical, hysterical, prejudiced, a ‘Nanny,’ and more recently a ‘jihadist’.

In 1993, a smokers’ rights group in the USA described me as ‘psychotic human garbage, a gibbering Satan, an insane psychotic just like Hitler, using fatuous, smarmy drivel and distortions, and diatribes full of putrid corruption, lies, conspiracy, and total censorship.’ They concluded by stating that I was ‘devoid of any sanity, any morality, or any human-being-ness of any kind’, was ‘nothing more than an evil-possessed, power-lusting piece of meat’ and they threatened to ‘utterly destroy’ me!

The group had made similar threats to a US government health official, so the last sentence – perceived by the FBI as a death threat – had to be investigated by the agency, and I was added-on to that investigation. At this point, I was offered 24-hour police protection by the Hong Kong government.

The industry twice threatened, very publicly, to take me to court. Nothing came of it, of course – I was on rock-solid ground on the facts – but such tactics were attempts to intimidate me, and a ploy to cast doubt on my credibility in the minds of the public.

Such offensive words, the death threat, and the menace of litigation, completely failed to divert me. I said, robustly and publicly, that I was absolutely not a suicidal type, and that if I were to be found ‘knocked down by a bus,’ the tobacco industry was guilty until proven innocent!

That is not hyperbole. I had to give evidence as an expert witness in a major tobacco smuggling trial, involving British American Tobacco cigarettes being smuggled into China. The chief witness was murdered, and eleven others disappeared. Another witness jumped out of a window – on the 22nd floor. I had to report to the Independent Commission Against Corruption that I was being followed. They put a stop to it, but it was an eerie experience, as was being cross-examined by a tobacco industry lawyer.

There have also been clandestine aspects to my work. In 1986, a go between phoned to tell me that a ‘Deep Throat’ associated with US Tobacco had informed him of a plan to imminently launch smokeless tobacco (sucking, chewing tobacco and snuff) in Hong Kong. To this day, I do not know the identity of ‘Deep Throat,’ not even whether it is a ‘she’ or a ‘he.’ Immediately, I contacted the Hong Kong government and helped to plan a ‘pre-emptive strike’ – a ban on the importation, manufacture and sale of smokeless tobacco products. Other whistle-blowers have contacted me from within the tobacco industry, always a sensitive and potentially explosive situation. For their safety, I will say no more.

Working In Dangerous Places

I have also worked in some very dangerous areas in Asian countries, some under martial law, some at war, some under attack by rebels in their own countries. I was in Cambodia giving a slide presentation when there was an almighty explosion and the ceiling started falling down. Everyone else dived under the tables. Perhaps my finest hour as a Brit: I simply said, ‘Next slide please.’ It turned out to be a captured ammunition cache that had been placed in the central square and blown up by the government, but with no notice to anyone.

In 1990, I was held at gunpoint by armed Mongolian palace guards who, seeing me appearing out of the dark at the Government guest house after an evening walk, had no idea who I was or what to do. I had to gently talk them down, in a language they did not understand. Incidentally, the Minister of Health in Mongolia told me that during that first visit, they held a cabinet meeting as they thought I might be a spy sent from the west. They had prepared a school project to present to me, but I was much more interested in the tax, economic and political issues regarding tobacco, even their border security in preventing smuggling. He said the cabinet had concluded I was not a spy, and instead I had highlighted the breadth of issues involved in tobacco control.

More recently, I have worked with the North Korean (DPRK) government on tobacco control on three occasions, but am probably safer there than in London.

Promoting Gender Equality

Less dangerously, I have been able to push for equal gender representation in public health policy-making, including data collection and in the wording and clauses of the WHO Framework Convention on Tobacco Control. I have been able to promote women for various international awards, to serve on international committees and to be invited to speak at major conferences. For example, when invited to assist the 10th World Conference on Tobacco or Health held in Beijing in 1997, I stipulated that I would work pro bono as long as at least half of the keynote plenary speakers, chairmen, and committee were female. Despite initial uncertainty from the organisers, the event turned out to be the “best conference ever” and set the standard for subsequent conferences.

I promote women because if women are not in those positions, then the issue of women and tobacco gets ignored. This resulted in some resentment from male (never female) colleagues in the early days, some of which I found very hurtful. Ultimately, though, I have found it useful being female. Some countries embarking on tobacco control found it less threatening to invite me to be an Advisor – and it’s my knowledge, experience and expertise, valued in Asia in both sexes, that gets results. In addition, being based in Asia and knowing Asia, but being British rather than Asian, helped me to be seen as politically neutral.

I have wondered if working in tobacco control today is as dangerous as it was. I think not. It does require a certain type of interested and involved person to go into the field, but public health has now moved to the mainstream of health sciences. There are also many more people working in the field – it is not as isolated as it was 40 years ago. Personally, I intend to work until I am 100 – I practice Tai Chi (taiji) and reserve my two sword programmes’ cut and thrust for continuing to fight the tobacco industry.

I have worn the ‘dangerous’ label as a badge of honour, but hope the day is near when women aren’t labelled “dangerous” simply for standing up to advocate for issues like health or gender equality. We wait.”

Read Judith’s original blog here:

Proud to be a dangerous woman – Dangerous Women Project

Today we hear from Dr Judith Mackay, identified by the tobacco industry as one of the three most dangerous people in the world.
Prof Judith Mackay’s GHA profile:

Philip Morris International Releases First “Update” on Their Scientific Research to Develop and Assess Potentially Reduced-Risk Products

Philip Morris International Inc. (NYSE/Euronext Paris: PM) today releases the first Reduced-Risk Product (RRP) Scientific Update, a regular publication on its research efforts to develop and assess a range of potentially reduced-risk alternatives to cigarettes. The report is available at The Update is meant to provide scientists, regulators and others a summary of PMI’s product development and assessment approach as well an overview of the latest studies, key peer-reviewed publications and presentations at scientific conferences. It is an important complement to PMI’s ongoing efforts to share its latest science, which include a dedicated website (

Prof. Manuel Peitsch, PMI’s Chief Scientific Officer, explains: “We are making significant efforts to develop and scientifically assess innovative products that generate a vapor in which harmful chemicals found in cigarette smoke are significantly reduced or eliminated while the taste, sensory experience and ritual characteristics of smoking are preserved as much as possible. Along with many public health experts, we believe innovative products backed up by solid science can play an important role to reduce the harm of smoking. Sharing our methodologies and findings allows feedback and review from external experts and regulators and can encourage further research in the field.”

PMI’s extensive research is inspired by the well-recognized practices of the pharmaceutical industry and in line with guidance of the U.S. FDA for Modified-Risk Tobacco Products (MRTPs). The Company today employs over 300 world-class scientists who conduct rigorous research, including laboratory and clinical studies, as well as ground-breaking systems toxicology. The assessment program also includes studies on actual product use and correct understanding of product communications, as well as post-market research.

Michele Cattoni, PMI’s VP Technology and Operations, further elaborates on the Company’s efforts: “Technological innovation is transforming our industry with a wide range of noncombustible nicotine products that have the potential to represent significantly reduced-risk alternatives compared to smoking. PMI has been, and will continue to be, a driving force in this transformation. Our ambition is that ultimately reduced-risk alternatives replace cigarettes to the benefit of smokers, society and our company.”


Philip Morris International Inc.

Philip Morris International Inc. (PMI) is the world’s leading international tobacco company, with six of the world’s top 15 international brands and products sold in more than 180 markets. In addition to the manufacture and sale of cigarettes, including Marlboro, the number one global cigarette brand, and other tobacco products, PMI is engaged in the development and commercialization of Reduced-Risk Products (“RRPs”). RRPs is the term PMI uses to refer to products with the potential to reduce individual risk and population harm in comparison to smoking cigarettes. Through multidisciplinary capabilities in product development, state-of-the-art facilities, and industry-leading scientific substantiation, PMI aims to provide an RRP portfolio that meets a broad spectrum of adult smoker preferences and rigorous regulatory requirements. For more information, see and

Foes of tobacco-tax hike pour millions into campaign

The campaign over a ballot measure that would raise the state’s tobacco tax by $2 per pack of cigarettes is shaping up as one of the most expensive among the long list of initiatives confronting California voters in November.

In August alone, the tobacco industry poured $20 million into fighting Proposition 56, which would increase the state’s tax on cigarettes for the first time since 1999 to $2.87 per pack, up from the current 87 cents, and impose comparable increases on other forms of tobacco. The tax would raise $1.4 billion and be used to fund health care, prevention programs and research.

Mike Roth, spokesman for the Yes on Prop. 56 campaign, said raising the cost of buying tobacco has been shown to be a successful deterrent to smoking.

Several independent studies, as well as research by the U.S. Centers for Disease Control and Prevention, found that increasing the price of cigarettes reduces the demand for them, particularly among teenagers and young adults. The most common way governments increase the cost of cigarettes is through a tobacco tax.

“Prop. 56 will increase our tax by $2 and protect kids and save lives,” Roth said.

The tobacco industry has already lost one major battle in California this year. In the spring, Gov. Jerry Brown signed bills raising the smoking age to 21 from 18 and putting e-cigarettes and other vaping products, many of them made by tobacco firms, under the same regulatory structure as tobacco.

Prop. 56 would also put vaping products under the tobacco umbrella, meaning the tax would also apply, for the first time, to e-cigarettes containing nicotine.

In all, the tobacco industry has poured $37 million into the opposition campaign, which is being led by a coalition of antitax groups. That’s $7 million more than the combined spending, pro and con, on initiatives to legalize marijuana, abolish the death penalty, speed up the death penalty, restrict ammunition sales and require adult film actors to use condoms.

In 2012, when voters narrowly defeated a $1 increase in tobacco taxes, opponents led by tobacco companies spent nearly $47 million against the measure.

“If we are going to tax smokers another $1.4 billion, then more should go toward helping them quit,” said Beth Miller, spokeswoman for the No on Prop. 56 campaign.

Miller acknowledged that devoting more money to such efforts wouldn’t have persuaded opponents to back the measure.

“When there are legal products for sale, there is no industry who would enjoy a targeted tax on them, whether it’s cigarettes or soda or gasoline,” Miller said.

“But the reality is, we have serious concerns about where the money goes,” she added.

Opponents also say they have problems with where the money raised by Prop. 56 wouldn’t go: One of their main complaints is that the measure “cheats schools out of $600 million.”

That’s how much education would receive next fiscal year if the money raised by Prop. 56 went to the general fund. By law, 43 percent of general-fund revenue raised goes to public schools and community colleges.

Money raised by Prop. 56 would go to a special fund, as does revenue from the state’s current tobacco tax.

“We have a problem with that, given the situation with school funding in California,” Miller said.

Miller declined to say whether the coalition would support the tax if Prop. 56 included more money for schools. Roth, for one, is skeptical.

“Since when has Big Tobacco been a champion for schools and our kids?” he said.

“The tobacco industry is using an age-old ploy — it’s an argument to undermine the integrity of the proposal,” said Larry Gerston, professor emeritus of political science at San Jose State University. “What they are trying to do is tear away voters with an argument that might resonate.”

With 17 ballot measures this year, the goal for opposition campaigns will be to confuse voters, said Bob Stern, former president at the Center for Governmental Studies.

“When voters get confused, they vote no,” Stern said.

Prop. 56 supporters have pulled in barely half of opponents’ total, but the $19 million they have already raised is millions more than they did in 2012, when the proposed $1-a-pack tax increase was defeated.

Roth said this year’s campaign has a bigger coalition working to pass the measure.

The bulk of the pro-Prop. 56 money has come from associations representing hospitals, doctors, dentists, insurance companies and labor unions.

Billionaire environmentalist Tom Steyer gave $1 million to the campaign last year. Planned Parenthood has also contributed substantially.

California’s current tobacco tax ranks 35th in the country, with the 87-cents-per-pack levy on cigarettes at barely half the national average of $1.60.

Roth said it’s only fair that smokers pay more, given that state taxpayers have to subsidize the cost of treating smoking-related diseases through the state’s Medi-Cal program for the poor. The Campaign for Tobacco-Free Kids, an antitobacco advocacy group, estimates that the state’s costs for smoking amount to more than $18 a pack when factoring in health care costs.

Under Prop. 56, Medi-Cal would receive the largest portion of the tax revenue — between $710 million and $1 billion in fiscal 2017-18, according to the nonpartisan Legislative Analyst’s Office. Schools would receive $20 million for prevention education. Five percent would go to the University of California for medical research of tobacco-related diseases.

Administrative expenses would be capped at 5 percent.

The Legislative Analyst’s Office said the amount each program will receive will decrease each year as fewer people take up smoking or quit due to prevention programs or the higher tax. That could put the state on the hook for continuing to fund those programs, critics argued.

Jim Knox, vice president of government relations at the American Cancer Society Cancer Action Network, a major supporter of Prop. 56, said he doesn’t buy that argument.

“The tobacco tax is more predicable and reliable than sales taxes,” Knox said. “The tobacco tax we passed 28 years ago is still providing a reliable steady source of income to the state. As the revenue goes down because people stop smoking, the costs also go down.”

Both the Yes and No campaigns have one thing in common, however.

They said they will spend whatever it takes to “get the message out.”

Melody Gutierrez is a San Francisco Chronicle staff writer. Email: Twitter: @MelodyGutierrez

History of tax plans

Previous ballot measures to raise the tobacco tax

1988 — Proposition 99
Impose tax of 25 cents per pack
Approved: 58 to 42 percent

1998 — Proposition 10
Raise tax by 50 cents per pack
Approved: 50.5 to 49.5 percent

2000 — Proposition 28
Repeal of Prop. 10 tobacco tax
Failed: 28 to 72 percent

2006 — Proposition 86
Raise tax $2.60 per pack
Failed: 48.3 to 51.7 percent

2012 — Proposition 29
Raise tax $1 per pack
Failed: 49.8 to 50.2 percent

2016 — Proposition 56
Raise tax $2 per pack

As world awaits WTO plain packaging decision, legislation spreads across the globe

The long-awaited decision of a World Trade Organisation panel on Australia’s decision to enforce standardised packaging on tobacco products has been ‘imminent’ for years. While the wait goes on, governments across multiple continents – including Africa, Asia and Europe – are introducing plain packaging legislation at an increasingly swift rate. While this suggests that the tobacco industry’s fight to hold back the spread of plain packaging is on the ropes, the anti-plain packaging lobby has not given up yet.

A major development in the last few months, which may have spurred on recent legislation announcements, was the World Bank dispute settlement body’s dismissal of a case brought by Philip Morris International against Uruguay’s implementation of enlarged label warnings on tobacco products. While this follows lawsuit losses against similar regulations in the UK, Norway and Australia, the Uruguay case has long been viewed as a test case, as it was the first time a tobacco group had taken on a country in an international court on this issue. The dismissal was therefore dubbed by commentators as “more than just a local triumph”, with one law lecturer suggesting it “may make it more difficult for tobacco companies to use lawsuits to produce a ‘chilling effect’ and so discourage countries from introducing tobacco control policies”.

In the months since that decision, a slew of national governments have announced or signed through plain packaging legislation. The push is now truly global. For instance, Gambia looks set to be the first African country to implement plain packaging, as the country seeks to maintain its award-winning anti-tobacco credentials. In Asia, both Malaysia and Thailand are well on their way to introducing a brand-free environment for tobacco, with pushes to introduce it in India and China too. Finally, following the European Court of Justice’s ruling in May that the new EU directive on tobacco products is valid, plain packaging laws came into effect in Hungary last month (with legislation that goes further than the current EU directive).

These recent developments follow similar moves in the last 12 months in Canada, New Zealand, Norway, and France. That’s not forgetting the UK following Australia’s lead by implementing its own standardised packaging laws in May (the same legislation in Ireland was delayed at the last minute). All told, the Canadian Cancer Society lists 14 countries where plain packaging is either now implemented or being formally considered (not including the aforementioned China, Gambia, India, Malaysia and Thailand).

But despite the tide appearing to turn, tobacco conglomerates are refusing to give up just yet. For example, Japan Tobacco International (JTI) recently commissioned research into the views that people hold of uniform packaging in Canada (following the Canadian government’s three-month consultation period about its possible implementation, which began in May). Some of the results were published in an op-ed in the Toronto Sun last week. They suggest low awareness of the consultation, with the results showing that “one in five Canadians had heard of the government’s intention to introduce plain packaging” and “only one in 10 understood what it was about”.

Of course, it is probable that a high proportion of citizens will be unaware of most government consultations – so those results are hardly a surprise. Additionally, plain packaging proponents will argue that this doesn’t have a bearing on the pros and cons of the regime itself. What it does show is, despite the repeated lawsuit losses, tobacco companies are refusing to give up the fight (and, as this very publication’s trip to the Dominican Republic in May demonstrates, cigar companies remain confident that the fight remains winnable).

Of course, this isn’t just a tobacco sector issue and trademark associations have long argued that plain packaging severely impairs the function of trademarks, makes counterfeiting easier and is in violation of international treaties. They have also warned that governments may decide to require plain packaging for other products or industries whose impact on public health is being scrutinised. On the latter, a ‘world first’ study released last week promotes the benefits of plain packaging on sugary products – suggesting that the predicted ‘domino effect’ could soon become reality.

Associations are therefore intent to keep fighting the spread of plain packaging. In June, for instance, INTA wrote to the Swedish government to register its opposition over the country’s decision to consider plain packaging for tobacco products.

The fight, then, goes on. However, as more countries line up to implement plain packaging regimes, it is getting harder to see how a comeback is possible – that is, unless the WTO panel delivers an upper-cut to Australia’s plain packaging regime early next year.