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December 15th, 2015:

Running away from “Tobacco Road”

Earlier this fall, my oldest son invited me to watch him run his first half marathon in Durham, North Carolina. While standing at the starting line, facing hundreds of runners of different ages, I could not help but be amazed by the irony of the situation: In the midst of a region in the United States known as “tobacco road,” there was tangible evidence of a significant, healthier turn in people’s norms and behaviors.

Why the irony, you may ask? After the U.S. Civil War in the 19th century, the tobacco industry became the backbone of North Carolina’s economy, and the city of Durham developed rapidly as a tobacco manufacturing center. Although cigarettes are no longer manufactured there, its historic district, where the race took place, still preserves the physical legacy of tobacco factories, which have now been converted into upscale apartment buildings and retail spaces.

While North Carolina is still the top tobacco-producing area in the United States, over the past two decades, tobacco employment, and the number of tobacco farming, processing and manufacturing establishments have declined steadily across all segments of the tobacco value chain in the U.S. In 1992, the U.S. tobacco industry employed over 80,762 people in 2,144 establishments. By 2012, this number had dropped to 42,531 workers in 1,955 establishments, a decline of 47.3% and 8.8%, respectively.

The continuous decline in the relative economic importance of the U.S. tobacco industry is due in large measure to the translation of medical and public health evidence, and knowledge about the negative health effects of tobacco use, into effective public policy measures, such as smoke-free laws and tobacco tax increases, which make these products unaffordable. Education campaigns and cessation programs have also helped to reduce the social acceptability of smoking and have changed consumption patterns. And funding from the 1998 Master Settlement Agreement–an accord between the state Attorneys General of 46 states, five U.S. territories, the District of Columbia, and the five largest U.S. tobacco companies, which requires the tobacco industry to pay the states approximately US$10 billion annually for the cost of health care for tobacco-related illnesses — is being used to support crop diversification away from tobacco.

Beginning with the first U.S. Surgeon General’s report on tobacco released in 1964, a broad consensus now exists that tobacco use is the single-most preventable cause of death and disease in the United States. As documented in the Healthy People 2020 report, for every person who dies from tobacco use in the United States, 20 more people suffer with at least one serious tobacco-related illness. Overall, smoking in the United States kills about 480,000 Americans a year and costs nearly $280 billion a year in health care costs and lost productivity.

Thanks to widespread application of anti-tobacco policy measures, smoking rates have declined significantly. Survey data from the U.S. Centers for Disease Control and Prevention (CDC) show a significant downward trend in current cigarette smoking among adults in the U.S.: from 42% in 1965 to 19% in 2011.

In spite of the significant progress achieved over the past 50 years, the 2014 Surgeon General’s report warns against complacency. The list of illnesses caused by smoking has grown, and smokers today have a greater risk of developing lung cancer than they did in 1964, even though they smoke fewer cigarettes, due to changes in the design and composition of cigarettes that raise health risks. It is notable that, for the first time, women are as likely as men to die from many of the diseases caused by smoking.

As the tobacco industry and tobacco use in the United States gradually but inexorably continue to fade away, there are other deep-seated and far-reaching changes taking place in social and cultural norms, attitudes and behaviors that have had an impact on the population’s health.

Scientific evidence and knowledge about the health benefits of regular physical activity, for example, are influencing youth and adults alike to participate in moderate and vigorous physical activities, such as running. Events such as the Durham Half Marathon reflect the “running/jogging/walking boom” that has grown over the past decade. Since 2004, Americans’ estimated total running/jogging participation (6+days/year) has increased 70% to a record of nearly 42 million people, across both genders.

Public health warnings and advice on effective ways to deal with the growing U.S. obesity and diabetes epidemic are also making more people cognizant about the food they eat. CDC data show that improvement in eating habits, including reductions in the average number of daily calories children and adults consume; a decline in the amount of soda Americans drink by about one-quarter since the late 1990s; and a rise in physical activity, have all contributed to the fall in the rate of new diabetes cases by about one-fifth, from 2008 to 2014.

On the trip back home from Durham, I concluded that all of us who are involved in supporting the realization of universal health coverage across the world now have a tremendous opportunity to contribute to the attainment of longer lives, free of preventable disease, disability, injury, and premature death. But to do so effectively in today’s era of competitive priorities and vested commercial interests, we need to advocate and support sound policymaking by disseminating and adapting to specific country contexts, good practices such as the ones observed in the United States. We also must bring evidence to bear on the broad social and economic benefits of public health action, as well as the costs of inaction.

We have a ways to go, but “running away from tobacco road” is a step in the right direction.

Ban on smokeless cigarettes kicks in

Smokeless cigarettes have officially been banned island-wide.

The ban, which comes into effect today, covers emerging tobacco products “currently not available in Singapore”, said the Ministry of Health (MOH) in a statement yesterday.

Other products that were also banned include dissolvable tobacco and products containing tobacco or nicotine that may be applied topically, injected or implanted in the body.

It will also include any tobacco or nicotine-containing substances meant to be used in e-cigarettes.

The ban was first announced in June this year and is part of MOH’s “ongoing efforts to protect the public against the known and potential harms of emerging tobacco products”.

These products join e-cigarettes, which have already been banned under the Tobacco Act.

The new ban is to “ensure that they do not gain a foothold or become entrenched in the Singapore market, which could stimulate demand for and increase the prevalence of tobacco consumption”, said MOH.

The ban that comes into effect today is part of a two-phase effort to bar such products from taking root in Singapore.

The second phase of the ban, which covers products already in the local market, will kick in from August next year.

The products that will be banned include nasal and oral snuff, which are smokeless forms of tobacco that are inhaled and chewed respectively; gutkha, which is a mix of tobacco, betel nut and catechu (herb) with lime, menthol, sandal oil, spice and flavourings; and khaini and zarda, which are flavoured chewing tobaccos.

MOH said this approach will give retailers time to “adjust their operating models away from such products, and deplete their existing stocks”.

Smokers who flout the ban can be fined up to S$10,000 or jailed up to six months or both. The maximum penalties will double if they are convicted for a second time.

Wrong for governments to ban vaping, smokers say in survey

The majority of smokers in Asia believe their governments would be wrong to ban electronic cigarettes if the devices were scientifically proven to be less harmful than tobacco, according to a recent survey.

The survey, which was carried out by regional consumer advocacy group, found that 75% of those polled were in favour of the government not preventing or delaying the introduction of less harmful alternatives.

The poll, which was recently conducted by a global market research company Ipsos, featured hundreds of respondents from Australia, Hong Kong, Macau, Malaysia, New Zealand, Singapore and Taiwan.’s co-founder John Boley said the respondents were also asked whether governments should encourage adult smokers to switch to less harmful alternatives and also ensure that they were not used by young people.

“There was very strong agreement,” he said during the “Harm Reduction in Asia – Developing a Regulatory Framework for E-cigarettes Symposium” here last week.

The symposium was organised by in the wake of the intense debate over the harm reduction potential of e-cigarettes as a less harmful alternative for adult smokers.

The group’s initiative comes at a time when the Hong Kong and Macau governments are considering completely banning the sales of e-cigarettes.

Authorities in Malaysia have already announced they will regulate rather than ban and proposals are expected to be reviewed and voted on by legislators in 2016.

Boley said 82% of the respondents felt that governments should encourage smokers to switch to less harmful alternatives.

“Incidentally, we also asked whether they thought they were okay with using e-cigarettes in their own country.

“There is an extraordinary degree of uncertainty as more of a third of the people polled across the region, or 36% of people in Hong Kong, do not know whether these things were legal or not.”

Boley also said 71% of the respondents agreed that e-cigarettes were a positive alternative to today’s conventional cigarettes while 70% of those interviewed would consider switching to e-cigarettes if they were legal, met quality and safety standards, and were readily available.

In August, Public Health England (PHE), the expert body that advises on public health in the United Kingdom, concluded that e-cigarettes were 95% less harmful to health than tobacco.

Meanwhile, Nav Lalji, founder of the Hong Kong-based Asian Vape Association, said he had been seeing more adult smokers switching to “vaping” in order to reduce or completely quit their tobacco dependence.

“We are seeing a rapid increase in adult smokers switching to vape products throughout Hong Kong.

“Most users are now ex-smokers who wished to quit but found traditional therapies, such as nicotine patches and chewing gums, ineffective.

“A lot of users strongly oppose a ban on e-cigarettes because this means that they will be forced to go back to using tobacco cigarettes, which ironically are not banned.”

He said that vaping was the most successful alternative to tobacco cigarettes due to its ability to replicate the act of smoking.


ASH Thailand has alleged that Philip Morris International has written to the country’s Ministry of Public Health in an effort to prevent a new law on tobacco control being passed. The law was due to be fast-tracked earlier this year following delays the public health minister reportedly blamed on the agriculture and finance ministries. It has since been further delayed amidst accusations of tobacco industry lobbying.

If passed, the new law will increase the legal age for purchasing cigarettes from 18 to 20, tighten advertising and marketing bans—including on social media—and prohibit tobacco industry corporate social responsibility initiatives. According to ASH Thailand Secretary General Prakit Watheesathokkij, PMI’s letter argued that Thailand’s existing tobacco control laws are sufficient for educating people about the harms of smoking and preventing uptake.

The tobacco industry is up against a formidable and very creative foe in Thailand, which has a long history of strong tobacco control action, with both ASH Thailand and the Thai Health Promotion Foundation providing leadership in the Southeast Asian region. The Thai Health Promotion Foundation’s latest campaign uses dead smokers’ lungs to send a direct message to smokers—literally.

The Message From The Lungs opens with blank ink dispersing into water and a paint brush making a bold black stroke on canvas, with the words: “This is not ordinary ink. Because it was the life’s work of a man. A man who spent 50 years of his life to make every drop of it…by smoking every day”.

It goes on to explain how Thai Health teamed up with the Faculty of Medicine at Chulalongkorn University to make ink extracted from the tar in lungs donated by smokers. The ink was then bottled and used to create artwork for ads. Samples were also distributed in public spaces as part of exhibitions to convince people to quit.

According to Thai Health, the campaign has resulted in a five-fold increase in quit smoking program participation.

United Nations agency gives EU a tobacco warning

Top official tells Commission to steer clear of the industry as it works on new smuggling controls.

The United Nations public health agency in charge of tobacco control has warned EU policymakers to keep their distance from industry as they consider reforms to fight cigarette smuggling.

The head of the World Health Organization’s Framework Convention on Tobacco Control secretariat, Vera Da Costa e Silva, wrote senior European Commission officials earlier this month, saying the EU’s close working relationship with tobacco companies to fight cigarette smuggling may violate Europe’s international commitments.

Citing a recent report in POLITICO, Costa e Silva said the “continuation of an illicit trade agreement with a major tobacco company” on the part of the Commission could be in contravention of international commitments, which state that obligations to clamp down on smuggling “shall not be delegated to the tobacco industry.”

One of the letters, addressed to Commission Vice President Kristalina Georgieva and Health and Food Safety Commissioner Vytenis Andriukaitis, points to growing concern over the Commission’s position on two key reform areas, in which the Commission is considering working closely with the world’s four largest tobacco companies.

The first area of concern is the anti-smuggling agreements which the Commission and EU national governments signed with tobacco producers Philip Morris, Japan Tobacco International, British American Tobacco and Imperial Tobacco Limited between 2004 and 2010.

The agreements are legally binding, enforceable anti-fraud deals involving EU and national counterfeit investigators and have been used as a way to compel tobacco companies to take responsibility for genuine tobacco products that end up on EU black markets, avoiding tax. The Philip Morris agreements expire in 2016 and Georgieva is now deciding whether to renew them.

In another letter, Costa e Silva raised concern about POLITICO’s revelations that anti-smuggling officials within the European anti-fraud office OLAF are both in favor of the Philip Morris deal being renewed and of a controversial packet-tracing technology being promoted by a consortium of tobacco companies.

“I have raised concerns regarding these matters with both [the directorate general for health and food safety] and OLAF,” Costa e Silva wrote, adding that OLAF investigators had expressed to POLITICO a preference for a “track and trace” technology being promoted by tobacco companies.

“I believe this to be of some importance, especially in light of the future membership of OLAF in the Panel of Experts on the Protocol,” Costa e Silva said.

Asked about the letters from Costa e Silva, a Commission official said: “As we said on numerous occasions, there are no negotiations with PMI, or any other companies about the ‘track and tracing’ in the tobacco agreement.”

The European Union is a signatory to the World Health Organization’s Framework Convention on Tobacco Control, an international treaty which came into force in 2005.

Under the convention’s framework, governments around the world are now considering an additional protocol, signed in 2012, which targets the illicit trade of tobacco products. That protocol must now be ratified and accepted by the 53 states and the European Union that have signed it.

The text of the protocol requires signatories to avoid outsourcing enforcement requirements to the tobacco industry and commits competent authorities to “interact with the tobacco industry and those representing the interests of the tobacco industry only to the extent strictly necessary” to implement the track and trace requirements.

The Commission is considering how best to balance its own “track and trace” provisions under the EU’s 2012 revised Tobacco Products Directive and the requirements of the World Health Organization protocol.

Under the directive, the EU will be required by 2019 to “ensure that all unit package of tobacco products are marked with a unique identifier” which will be “irremovably printed or affixed” to cigarette packets. The Commission is preparing a second feasibility study to examine which type of technology it should recommend EU member states employ.

The tobacco companies are lobbying vigorously for the adoption of their in-house technology, called Codentify. However, other packaging and printing companies are also in the running, including the Swiss-based Sicpa, a high-tech printing company which provides package tracking technology in a number of countries.

The European Carton Makers Association is also watching the process keenly, with a number of its members preparing to counter bids of both SICPA and Codentify if and when public tenders are issued.