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October 25th, 2016:

Uruguay: A giant leap to prevent tobacco-assisted suicide

Tobacco is arguably one of the most significant threats to public health we have ever faced. Since the publication of the landmark U.S. Surgeon General’s Report on Tobacco and Health in 1964, that provided evidence linking smoking to diseases of nearly all organs of the body (see graph below), the international community slowly began to realize that a century-long epidemic of cigarette smoking was causing an enormous, avoidable public health catastrophe across the world.

History is not linear. The road to progress tends to be circuitous and full of uncertainties, and even more than a few steps backwards. In spite of this reality, at certain points in time, we have to admire those individuals and countries who have stepped in to shine the light to allow us all to move forward.

Recently, Uruguay, a small country in South America, offered us a good example of how a government that is committed to protecting the health and wellbeing of its people was able to withstand for more than 6 years the pressure of litigation from a giant multinational tobacco company, whose annual revenues of more than US$80 billion exceed the country’s gross domestic product of close to US$50 billion. As discussed in detail below, Philip Morris started proceedings in February 2010 claiming that the comprehensive tobacco control measures adopted by the Government of Uruguay since 2003 violated obligations under international trade and investment arrangements.

We are heartened by the resolve of leaders in Uruguay, which reflects the “garra charrúa” or the “resourceful, daring, and never to give up attitude” of the Uruguayan people. Perhaps in this case is apt to paraphrase the words of Apollo 11 astronaut, Neil Armstrong, after he stepped onto the lunar surface for the first time in 1969, to describe Uruguay’s victory as “one small step for a country, one giant leap for global tobacco control.”

Although cigarettes are “legal” goods that are produced, traded, and sold across the world, it is an indisputable fact, as one of us can attest as a specialist in vascular disease, that tobacco acts in a number of direct and indirect ways to cause damage to our blood vessels, heart and brain. Over time, these injuries raise blood pressure, reduce ability to tolerate exercise, and increase risk for blood clots and cancer.


Indeed, the bleak truth is that tobacco is the only “legal” product that kills when used as advertised. Despite decades of accumulated epidemiologic and experimental evidence on the causal relationship between tobacco smoking and lung cancer and other diseases, as well as significant progress achieved in reducing tobacco use globally since the adoption in 2005 of the WHO’s Framework Convention on Tobacco Control (FCTC), smoking remains one of the largest causes of preventable disease and death, with nearly 80% of the world’s one billion smokers living in developing countries. Data from the 2015 Global Burden of Disease study show that tobacco-attributable deaths and disability-adjusted life years (DALYs) lost have continued to rise across the world because of increases in population and aging that overwhelm declines in both exposure and risk-delated rates of related disease burden. In 2015, more than 7.1 million people died due to all tobacco smoke-related cases, up from 6.8 million people in 2005.

The lawsuit by Philip Morris, the biggest tobacco company in the world, against Uruguay argued that the country’s rules on tobacco packaging negatively impacted its intellectual property rights and sales in violation of the terms of a bilateral investment treaty between Uruguay and Switzerland, where the tobacco company has its headquarters. At its core, the lawsuit opposed provisions in two tobacco control measures adopted by the Government of Uruguay for protecting public health from the adverse effects of tobacco promotion, including false marketing that certain brand variants are safer than others, even after misleading descriptors such as “light,” “mild,” “ultra-light” were banned, and to increase consumer awareness of the health risks of tobacco consumption and encourage people, particularly the youth, to quit or not to take up smoking. Ordinance 514 issued by the Ministry of Public Health in 2008 requires each cigarette brand to have a “single presentation” and prohibits different packaging or “variants” for cigarettes sold under a given brand. Presidential Decree 287 of 2009 mandates an increase in the size of prescribed health warnings of the surface of the front and back of the cigarette packages from 50% to 80%, leaving only 20% of the cigarette pack for trademarks, logos and other information. The application of these provisions forced Philip Morris to withdraw most of its brands (such as Marlboro Red, Marlboro Gold, or Marlboro Green) from retail stores in Uruguay.

On July 8, 2016, however, the International Center of Settlement of Investment Disputes (ICSID), an independent arm of the World Bank Group, dismissed the lawsuit in its entirety and ruled that Uruguay should be awarded compensation for all the expenses and costs associated with defending against these claims. In essence, the ruling accepted the claim made by the Government of Uruguay that its anti-tobacco measures were “about protection of public health, not interference with foreign investment.” We should be clear, as Uruguay’s President, Dr. Tabaré Vázquez, an oncologist, stated in a televised address to the country after the ruling, the ICSID award reinforces that “it is not acceptable to prioritize commercial considerations over the fundamental right to health and life.”

This landmark international ruling came at just the right time, as India prepares to host in early November 2016, the Conference of the Parties (COP7), bringing together 180 Parties, which includes almost every country in the world, as well as regional economic integration organizations like the European Union, for reviewing the implementation of the WHO’s FCTC and the Protocol to Eliminate Illicit Trade in Tobacco Products.

At COP7, the victory of Uruguay needs to be highlighted echoing the words of former New York City Mayor Michael Bloomberg, an international public health champion, who provided financial support to help Uruguay deal with the litigation: “No country should be ever be intimidated by the threat of a tobacco company lawsuit, and this case will help embolden more nations to take actions that will save lives.” Indeed, countries across the world have now an important precedent to follow for the benefit of their people.

Medford raises tobacco purchasing age from 18 to 21

Joining the majority of surrounding cities and towns and more than 100 statewide, Medford has raised the minimum age to purchase tobacco products from 18 to 21.

The Medford City Council voted unanimously in favor of amending the city’s smoking ordinance Oct. 18 after City Councilor Adam Knight proposed the change several weeks earlier.

Knight had worked with Maureen Buzby, coordinator of the Mystic Valley Tobacco Alcohol Program, to draft the revised ordinance. Medford is the last of the Mystic Valley coalition’s seven municipalities to raise the minimum age for purchasing tobacco products to 21.

“We’re actually the weak link in the chain at this point in time where individuals in other communities that have a legal [purchasing] age of 21 can actually come to Medford to purchase cigarettes,” Knight said during the council’s Sept. 20 meeting, when he proposed the ordinance change.

In addition to the Mystic Valley cities and towns – Malden, Melrose, Stoneham, Reading, Wakefield and Winchester – Medford joins more than 130 municipalities statewide that have raised the minimum age for buying tobacco products.

A 2015 report by the Institute of Medicine found that passing similar legislation nationwide would lower overall smoking rates by 12 percent and prevent 16,000 cases of preterm birth and low birth weight in the first five years of the policy.

According to the 2011 National Survey on Drug Use and Health, 90 percent of smokers reported starting smoking before the age 21.

“The [Medford] Board of Health is very happy that you’re moving forward with this resolution,” said Board of Health Director MaryAnn O’Connor during the Sept. 20 council meeting.

Knight’s fellow councilors also expressed strong support for the change.

“Nobody supports this more than me,” Councilor Rick Caraviello said. “My mother passed away from smoking, and I don’t think [a person] should.”

Medford ranks low in compliance checks

While praising the council for the ordinance change, Buzby said she hoped Medford would also provide funding to increase the number of compliance checks conducted throughout the city.

Twice each year, Buzby visits businesses in Medford and the other Mystic Valley cities and towns to see whether establishments sell tobacco products to youth under 21 – or previously, under 18.

“Medford stores are probably compliance-wise in the bottom half of the seven [municipalities],” Buzby said. “So we could use some improvement in compliance. However, this particular region – the Mystic Valley region – has much higher compliance than most of the other regions in the state. So we do very, very well in this region. Medford could use a little improvement.”

Buzby said the state provides funding only for under-18 compliance checks because the minimum age to purchase tobacco under state law remains 18 (a campaign to raise the minimum age to 21 throughout the state has received support in the state Senate, however).

Therefore, Buzby said she hopes Medford provides an additional $300 in funding so that she can conduct compliance checks with 19 or 20-year-old youth, now that Medford has raised the minimum purchasing age to 21.

“I think it’s really important if you pass this resolution to do an additional check with a 19 or 20 year old so that you’re closer to that legal age and you’re getting a truer compliance check,” she said.

Botswana: Tobacco levy to fund anti-smoking initiatives

The Ministry of Health and Wellness has set up a task team to consider how the tobacco levy could be channelled towards funding tobacco control activities, a senior health official has said.

Chief health officer, Setshwano Mokgweetsinyana told participants at the inaugural Anti-Tobacco Network (ATN) public lecture at the University of Botswana recently that communication would soon be issued detailing the criteria to access the funds.

The Government introduced the levy in 2014 with the objective of funding anti-tobacco initiatives and other related activities.  The health ministry explained the development was in recognition of the contribution of tobacco as the main risk factor for a number of chronic diseases, including cancer, lung diseases and cardiovascular diseases.

People trying to quit smoking don’t always focus on tobacco cessation

Fifty per cent of statements made by smokers during counselling sessions designed to help them stop have nothing to do with quitting, a UBC study has found.

The study, which focused on conversations smoking cessation counsellors in the United Kingdom had with their clients, also found the 50 per cent of statements that did relate to quitting mostly focused on medical aids such as smoking cessation drugs, nicotine patches or inhalers.

“These findings may indicate that people trying to quit need time to talk about a variety of topics to feel comfortable talking with their practitioner about smoking,” says Heather Gainforth, an assistant professor of health and exercise sciences at UBC’s Okanagan campus. “It also highlights the importance of providing smokers with the opportunity to receive counselling about pharmaceutical aids that can help them quit.”

As part of her study, Gainforth reviewed the transcripts of 15 smoking cessation interviews and coded all 1,429 statements made by smokers during counselling sessions.

The data collected is part of a larger, ongoing study aimed at determining what tools and supports best help smokers quit.

According to a 2012 report from the UK’s National Centre for Smoking Cessation and Training, 20 per cent of adults in England reported smoking in 2010 and smoked an average of 12.7 cigarettes per day. In 2010/11 1.5 million hospital admissions (5 per cent) were estimated to be attributable to smoking, up from one million in 1997, and 18 per cent of deaths of adults over 35 were estimated to be smoking related.

Gainforth’s research was recently published in the British Journal of Health Psychology.

Leaked Big Tobacco document suggests it used convenience-store, anti-contraband groups as lobbyists

Across Ontario and Quebec, city and town councils passed a wave of similar resolutions, urging provincial governments to crack down on the scourge of contraband tobacco.

It was no coincidence: the municipalities had all been lobbied by convenience-store and anti-contraband associations.

The same, seemingly independent groups have also called for a freeze on legal tobacco taxes, opposed bans on menthol cigarettes and, today, are fighting the federal government’s plan to require plain packaging for smoking products.

But a leaked Imperial Tobacco document suggests that 2012 lobbying campaign was no grassroots movement, and that the retail and contraband organizations have for years been used as surrogates by the cigarette giant to promote its own interests.

The internal PowerPoint presentation describes deploying the convenience-store groups and the National Coalition Against Contraband Tobacco — both at least partly funded by the tobacco industry — to promote fears about contraband, push for action against it and keep taxes down on legal ones.

The document focuses at length on what it calls Project M&M: “Mobilizing municipalities to pressure for Big Government action.”

It then refers to cases where the convenience-store associations or anti-contraband group garnered media coverage and convinced dozens of local councils to pass those resolutions.

One slide in the August 2012 presentation suggests Imperial’s tactics worked, noting there had been no increases in tobacco taxes since 2008.

“Our campaigns have delivered some success.”

The document — a presentation made to parent company British American Tobacco — was leaked to a public-health researcher by a company “whistleblower,” said Melodie Tilson of the Non-Smokers’ Rights Association.

“This presentation makes it really clear,” she said. “They are orchestrating various organizations and using them basically as their puppets to ensure governments don’t enact effective tobacco-control measures.”

Groups like the convenience stores mislead the public and elected officials when they fail to make clear their close ties to Big Tobacco — whose products are one of the biggest sources of chronic disease and death in Canada, said Tilson.

She and other anti-smoking advocates agree that contraband cigarettes — whose cheap prices may be encouraging more smoking — are an important issue.

But they note the groups have not only called for enforcement action against the illicit trade, but opposed tax increases, bans on flavoured cigarettes and even the move to hide tobacco “power walls” in stores.

In fact, there is other evidence of their close links to the industry, including at least three former tobacco-company executives who are now leaders in the Ontario, Quebec and national convenience-store associations.

It’s a bit peculiar that some are hanging their hats on this particular PowerPoint presentation, in that it addresses contraband … which I think all of us should be concerned about
The CEO of the Ontario group, David Bryans, for instance, worked at what is now JTI-MacDonald until 2002, at one time as director of domestic sales. He has led either the Ontario or Canadian convenience-store trade groups since 2003.

But the current president of the Canadian Convenience Stores Association, Satinder Chera, denied his group acts at the behest of the tobacco industry.

Cigarette companies are among 60 national firms who are part of the association, representing the stores’ major suppliers from soft-drink makers to oil companies, he said.

The association lobbies on a “slew” of issues, and makes no apologies for opposing contraband, said Chera.

“It’s a bit peculiar that some are hanging their hats on this particular PowerPoint presentation, in that it addresses contraband … which I think all of us should be concerned about.”

Still — like colleagues from his and the other groups at various legislative committee hearings — he refused to disclose what proportion of the association’s funding comes from the tobacco industry.

Jeffrey Guiler, an Imperial Tobacco spokesman, said in a statement that the company works with a variety of groups on a “multitude of issues,” including contraband.

“This criminal activity harms honest small-business owners. They care about their business and we work with their umbrella groups to advocate for their best interests.”

The National Coalition did not respond directly to the suggestion it is part of Imperial’s lobbying campaigns, but noted in a statement that its 18 member organizations have convinced governments to act against “this growing (contraband) threat.”

The Imperial Tobacco presentation lists the company, the convenience-store groups and contraband coalition side by side as conducting various campaigns for years to oppose illegal cigarettes and to “freeze taxes.”

Then it asks “how to keep the pressure on” and answers by describing the 2012 Project M&M campaign involving the same players, but leaning on Quebec politicians during an election year and on municipalities in two provinces.

Through such “front groups,” the tobacco company essentially co-opted politicians and other “innocents,” charged Cynthia Callard of Physicians for a Smoke-Free Canada.

“If I was a councillor in any of those municipalities that had passed a resolution in good faith,” she said, “I would feel used.”

Higher Smoking Age, Tobacco Advertising Ban Approved

One of a number of government-mandated visual warnings which have been printed on packs of cigarettes sold in Thailand.

The interim cabinet on Tuesday approved a measure to raise the minimum smoking age to 20 from 18.

The increase was approved along with a raft of related measures to effectively ban all forms of advertising for the industry.

It also expanded the legal definition of tobacco products to apply to electronic devices and water pipes known locally as barakoo.

For more than a decade, cigarette use has declined in Thailand through concerted private- and public-sector efforts.

The measures will go to the interim legislature for adoption.

Nicotine and Carbonyl Emissions From Popular Electronic Cigarette Products

Nicotine and Carbonyl Emissions From Popular Electronic Cigarette Products: Correlation to Liquid Composition and Design Characteristics

Ahmad EL-Hellani, PhD Rola Salman, BS Rachel El-Hage, MS Soha Talih, PhD Nathalie Malek, MS Rima Baalbaki, MS Nareg Karaoghlanian, BE Rima Nakkash, PhD Alan Shihadeh, ScD Najat A. Saliba, PhD



Available in hundreds of device designs and thousands of flavors, electronic cigarette (ECIG) may have differing toxicant emission characteristics. This study assesses nicotine and carbonyl yields in the most popular brands in the U.S. market. These products included disposable, prefilled cartridge, and tank-based ECIGs.


Twenty-seven ECIG products of 10 brands were procured and their power outputs were measured. The e-liquids were characterized for pH, nicotine concentration, propylene glycol/vegetable glycerin (PG/VG) ratio, and water content. Aerosols were generated using a puffing machine and nicotine and carbonyls were, respectively, quantified using gas chromatograph and high-performance liquid chromatography. A multiregression model was used to interpret the data.


Nicotine yields varied from 0.27 to 2.91 mg/15 puffs, a range corresponding to the nicotine yield of less than 1 to more than 3 combustible cigarettes. Nicotine yield was highly correlated with ECIG type and brand, liquid nicotine concentration, and PG/VG ratio, and to a lower significance with electrical power, but not with pH and water content. Carbonyls, including the carcinogen formaldehyde, were detected in all ECIG aerosols, with total carbonyl concentrations ranging from 3.72 to 48.85 µg/15 puffs.

Unlike nicotine, carbonyl concentrations were mainly correlated with power.


In 15 puffs, some ECIG devices emit nicotine quantities that exceed those of tobacco cigarettes. Nicotine emissions vary widely across products but carbonyl emissions showed little variations. In spite of that ECIG users are exposed to toxicologically significant levels of carbonyl compounds, especially formaldehyde. Regression analysis showed the importance of design and e-liquid characteristics as determinants of nicotine and carbonyl emissions.


Periodic surveying of characteristics of ECIG products available in the marketplace is valuable for understanding population-wide changes in ECIG use patterns over time.

Vape cigarette battery sets fire to luggage in aircraft cargo hold

An e-cigarette battery set fire to an air passenger’s luggage while it was being loaded into the hold of a United Airlines flight, according to reports.

Baggage handlers at Seattle-Tacoma International Airport spotted smoke coming from a bag as they stowed it in an aircraft destined for Houston, said Seattle’s Komo News.

Firefighters extinguished the flames and traced the source of the fire to a vape cigarette battery which was connected to a charger, reported the newspaper. The owner of the bag was identified, and the flight took off slightly delayed.

United Airlines has been contacted for comment.

E-cigarettes are powered by lithium-ion batteries – a particularly volatile type of rechargable cell that has been linked to spontaneous fires in smartphones and other electronic devices.

The US Department of Transportation and the UK’s Civil Aviation Authority (CAA) prohibit the transportation of electronic cigarettes in checked-in baggage, due to the volatility of their lithium-ion batteries. They must be carried in hand luggage, but using vapes in the cabins of commercial flights is also illegal.

This isn’t the first incident of its kind. In 2014, firefighters at Logan International Airport in Boston, Massachusetts, were called to extinguish a passenger’s vape that had ignited inside a cargo hold. And in March this year, a Delta Airlines flight from Atlanta International to St Louis was delayed when a passenger’s e-cigarette set light to their carry-on bag during boarding.

United Airlines’ baggage guidance states: “Electronic cigarettes and personal vaporizers will not be accepted in checked or gate-checked baggage. These items may be stowed in carry-on baggage or on your person during travel, however, the use and charging of e-cigarettes and personal vaporizers is prohibited onboard all United flights.”

The CAA states that “e-cigarettes, e-cigars, personal vaporizers and electronic nicotine delivery systems all contain lithium batteries, which must be carried in the cabin and not in your suitcase”. See the CAA website for full guidance on travelling with lithium-ion batteries in phones, cameras and e-cigarettes.

“We know from recent incidents that e-cigarettes in checked bags can catch fire during transport,” said US Transportation Secretary Anthony Foxx when e-cigarettes were banned from hold luggage in America. “Fire hazards in flight are particularly dangerous. Banning e-cigarettes from checked bags is a prudent safety measure.”

Earlier this month, it was announced that Samsung would halt the production of its lithium ion-powered Note 7 phone after multiple reports of the devices catching fire. Airlines such as Qantas, Singapore Airlines and Cathay Pacific had prohibited passengers from bringing the smartphones on board.

Detection of 5-hydroxymethylfurfural and furfural in the aerosol of electronic cigarettes

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