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Czech Republic: BATgets round weak adbanThe Czech Republic’s current advertisingban dates from 2003, but there are strongsigns that it needs to be strengthened. Thelaw bans all forms of advertising andpromotion of tobacco products, includingsponsorship. Unfortunately, however, theuse of tobacco products’ names or mentionof their supposed attributes is only bannedon radio and television. This is currentlyexploited by BAT’s Pall Mall brand, whichhas been promoting a range of clothes onbillboards in Prague. In addition, BAT usedthe Pall Mall brand name in its sponsorshipof the country’s world renowned filmfestival, Febiofest, in both 2006 and 2007.Such activities apparently get round thecountry’s laws, though to date, there havebeen no serious challenges.
Not content with such brand stretchingand promotion of the brand name inassociation with a much publicised culturalactivity, BAT also uses its continuingmarketing activities for lobbying purposes,to try to prevent additional measuresknown to be effective in reducing tobaccoconsumption. For example, an ad forFebiofest in 2006 proclaimed not onlyBAT’s status as the principal sponsor ofthe film festival, but also its support for‘‘efficient ventilation and a pleasant envir-onment for smokers and non-smokers inselected Prague facilities.’’ Similarly, usinga favourite tobacco sophistry to try toprevent tax rises by diverting attention tothe sale of fake and smuggled cigarettes,ads in this year’s Fabiofest newspaper said,‘‘Cigarette forgers did the state out of taxesfor 2006 of at least 1.6 billion crowns[about US$78 million]. This money couldpay for the filming of 50 full length films.500 sports cars for the mafia, or 50 fulllength films? Choose for yourself.’’
Of course, BAT knows full well that thisis not a choice for the government, farless one that the general public can make.But it is free propaganda that will embeditself in the public psyche, and that of thecountry’s elected representatives, when itis time for those continuing acts ofpolitical bravery and clear sightedness
that are regularly required to enforceand strengthen tobacco control laws.
EVA KRALIKOVACharles University, Prague, Czech Republic;
Mongolia: proportionof tobacco tax forhealthIn March 2007, Mongolia started todivert a proportion of its tobacco taxrevenue towards a new health promotion
foundation. This followed a tobacco con-trol law that required that the foundationbe established ‘‘to enhance healthy life-styles and reduce tobacco consumptionamong the population.’’
In the debate leading up to the newlaw, it was reported that ‘‘some of thelawmakers insisted that the excise tax ontobacco should be accumulated in anational fund to fight hazards of tobaccoand be used for anti-smoking advertisingcampaigns.’’
While the amount of funds for thenew foundation are modest—2% of thetobacco tax revenue, or around US$180 000
All articles written by David Simpsonunless otherwise attributed. Ideas anditems for News Analysis should be sentto: [email protected]
Czech Republic: billboard in Prague promoting Pall Mall clothes, August 2007
Czech Republic: one of BAT’s ads promoting its sponsorship of the Febiofest film festival and making apoint about sales of fake cigarettes.
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per year—it represents a fairly rare movefor a developing country. Only a few othersuch countries dedicate any of their tobaccotax revenue to health related purposes—Estonia, Poland, Egypt, Thailand, Korea,Taiwan and Qatar. All these have higherper capita incomes than Mongolia.
Despite this progressive move, Mongoliastill has plenty of scope for improvedtobacco control. A recent survey in 2005indicated that smoking prevalence wascurrently 43.1% for men and 4.1% forwomen. In particular, there is a need tofurther raise the overall level of tobacco tax,which, including value added tax andcustoms duty, is only around 40% of theprice paid by the smoker. Without higherexcise taxes, tobacco will continue to berelatively cheap owing to Chinese importsand Mongolia’s own domestic products.
There is also scope in Mongolia forimproving compliance with the currentsmoke-free environments law that limitssmoking to designated areas. There mayeven be a need for a new smoke-free lawthat is more comprehensive, with com-plete restrictions on smoking in all publicplaces and hospitality venues.
NICK WILSONOtago University, Wellington, New Zealand
TSETSEGDARY GOMBOJAVMinistry of Health, Mongolia;
Sri Lanka: BAT and theinfluence gameAs members of the south Asian diasporaaround the world celebrated the 60thanniversary of the partition of India, thecreation of Pakistan and the indepen-dence of the two countries from theirformer colonial rulers, some in the regionhad cause to ponder how little somethings had changed. In another formerBritish colony just to the south, tobaccocontrol advocates saw how the futurehealth of their people continued to bejeopardised by the activities of a transna-tional tobacco company based in the UK.Moreover, they noted just how similar itstactics remained to those used for gen-erations back in ‘‘the old country’’ forfostering influence with the government.Even if the ‘‘old boy’’ network had fadeda bit at home, it appeared to be alive andwell in Sri Lanka.
As the 8th international congress onAIDS in Asia and the Pacific (ICAAP) wasabout to open in the capital, Colombo, inAugust, health advocates learned that thechairman and another director of BAT’s90% owned subsidiary, CTC (CeylonTobacco Company), were members ofthe conference finance committee.Public health workers maintained that
their presence was a serious conflict ofinterest, and said it was yet another subtlestrategy of BAT to build its image as asocially responsible company. After all, theyreasoned, since BAT used the experience ofits board members to further its businessinterests, both in the boardroom andbehind the scenes, it seemed unlikely thatthe company would be averse to exploitingthe service rendered to the conference by itsdirectors, in whatever capacity, if thatwould give it an advantage in maintainingbusiness as usual.
The two BAT men, CTC’s chairman MrKen Balendra and his fellow director MrDeva Rodrigo, between them must have avast list of influential contacts. Mr Balendraalso chairs the South Asia Regional Fundsponsored by the CommonwealthDevelopment Corporation for investmentin South Asia, and in the past has beenchairman of the Ceylon Chamber ofCommerce, the Securities and ExchangeCommission, and the Insurance Board ofSri Lanka. Mr Rodrigo’s CV, too, contains awealth of blue chip appointments.
The aim of tobacco control legislation, ifit is really to be effective, must be to reduceconsumption, for that holds by far greatestpotential to prevent the vast amount ofpremature death, disease and disabilitycaused by tobacco. And good works byworthy individuals must be worth some-thing to BAT when trying to persuadegovernments not to pass tobacco controlproposals that might actually be effective,which would mean reducing consumption.
Thirty years ago, in the infancy oftobacco control in the UK, tobacco
companies such as BAT had peopleembedded in every conceivable part ofBritish public life, from government andquasi-government organisations, to cul-ture, sport and just about anything elsethat enabled contact with those whoultimately held the key to their long termfuture. It is only in comparatively recenttimes that members of most self respect-ing organisations have preferred not to sitdown with the brown mafia.
Despite what is now a long history ofactive tobacco control exposing the manytricks of the tobacco industry to recruitand keep Sri Lankans smoking, citizenslike the BAT directors, albeit with a longrecord of public service as well as top levelbusiness and commercial experience, arestill available for appointment by BAT. Ofmore concern is that there still seem to bemany in the health community, as well asin government, who do not understandhow it all works, and continue to appointthem to prestigious positions where,however innocent the individuals’ inten-tions may be, BAT can reap the mostinappropriate corporate rewards.
Cameroon:disappearing ads markgood startCameroon, set in the crook of west Africa,is one of the many African countries that,while not often in the news, have tendedto be open playing fields for tobaccocompanies. Depending on economic fac-tors, some of them have at times seemedlike adventure playgrounds for tobaccoadvertisers. In the past, like so manysimilar developing countries, Cameroon’sfrail economy, with all the immediateconcerns of any low income developingcountry, helped ensure that tobacco con-trol never became a dominant issue.Apart from smoking bans in healthcarefacilities, and restrictions in governmentbuildings and educational facilities, itshowed nearly a full house of ‘‘notregulated’’ scores in surveys of tobaccocontrol measures and infrastructure. It istherefore just the sort of country whereone could expect to see some noticeablechanges deriving from the World HealthOrganization’s Framework Convention onTobacco Control (FCTC).
Cameroon signed the FCTC in May2004 and ratified it less than two yearslater, in February 2006. Before that,smoking prevalence was low among theAfrican population—around 36% amongall adults—but higher in the country’sexpatriate population, who tend to be afocus for advertising for their significantlylarger incomes and their perceived statusas leading the consumer good life that
Sri Lanka: ICAAP logo
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advertisers wanted to sell to everyoneelse. BAT has a third of the market, themore expensive end, and its advertisinghas been fairly predictable. Offers ofcigarette packs with coupons offeringthe chance to win luxury prizes havebeen typical, as used by BAT as recently asthis year to promote its Pall Mall brand.Other Pall Mall billboards, featuring agiant picture of the brand, have claimed,‘‘5,000,000 people smoke one cigarette.’’At around a fifth of the adult population,this would make Pall Mall significantlythe most popular brand, though Benson& Hedges, Marlboro and other brandadvertising was also widespread.Tobacco sports sponsorship included golftournaments in which prizes includedboxes of cigarettes, irrespective ofwhether the winner was a smoker.
Now, however, tobacco billboards arereported to have largely disappeared,though cigarette emblazoned umbrellasat sales booths and restaurants are stillcommon. Tobacco manufacturers, nodoubt using the hospitality trade to dotheir dirty work, will squeal loudly if andwhen the government acts to removeremaining promotional items, but thatand many other measures will costnothing to implement. Health warnings,for example, currently contain classictobacco industry language to indicateuncertainty about smoking causing dis-ease: printed in both French and English,
they warn only that ‘‘Tobacco may bedangerous to your health.’’ It is to behoped that the lengthy FCTC negotiationprocess made Cameroonian health offi-cials realise that such tentative state-ments are no longer acceptable, and thattheir country can have the same sort ofwarnings as the international leaders bymeans of a simple ultimatum to themanufacturers.
While Cameroon is something of acultural and market leader for some ofits neighbours, such as Chad and theCentral African Republic, the economicchallenges it still faces make it unlikely tobe a prime target for internationaltobacco companies. However, as long aspeople are paid to try to get citizens in anycountry to smoke, they will try to getround legislation. With tobacco control arelatively recent item on the agenda,countries such as this may offer instructivecase histories as the process of implement-ing and enforcing legislation under theFCTC unfolds.
Australia: WARNING:outdated pack healthwarnings areaddictive—to tobaccocompaniesHealth groups in Australia have warnedgovernments to close stockpiling loop-holes when introducing new picturebased health warnings on tobacco pack-ets. Under Australian law, all tobaccopackets manufactured from March 2006must by law display the new graphics—alerting smokers and potential smokers tothe full range of diseases and disabilitiescaused by tobacco products, and how toget help with quitting. But a surveycarried out by ASH in late July this yearfound that 70% of Sydney tobacco retail-ing shops were still selling some tobaccoproducts with text only warnings—fully16 months after the graphic warningswere introduced.
ASH surveyed 40 shops (10 super-markets, 10 general ‘‘convenience’’ stores,10 petrol stations and 10 tobacconists) inthe city and inner suburbs. At 28 shops,ASH was able to buy either cigarettes orroll your own or cigars carrying the oldwarnings—including from all 10 of thetobacconists, eight of the conveniencestores and five each of the supermarketsand petrol stations. In the big super-market chains and petrol stations whereturnover was high, there was less evi-dence of stockpiling. In all cases, less than5% of the packets in the shops carried theoutdated warnings.
Tobacco companies in Australia foughtlong and hard to delay and downsize thegraphic health warnings, shown byresearch to be more effective that textonly messages. Now, by stockpiling theold packets, the tobacco industry con-tinues to delay giving smokers the fullpicture about the diseases and disabilitiescaused by tobacco products. ASH is alsoconcerned that stockpiling can be used bythe industry to create doubt over accuracyof declines in smoking prevalence figuresthat are based on self reporting.
Tobacco kills more than 15 000Australians a year and still needs muchtougher regulation to protect smokers—and potential smokers, who are mostlychildren. Before introducing the newwarnings, the Australian governmentwas warned about the dangers of stock-piling, and advised that legislation couldand should require withdrawal of stockwith old warnings by a certain date. Thegovernment chose to ignore this advice.The Australian experience emphasises theimportance of including firm deadlines toprevent stockpiling in all measures tointroduce new warnings.
STAFFORD SANDERSAction on Smoking and Health (ASH) Australia;
World: a guide toevaluating FCTC ledpoliciesSince the Framework Convention onTobacco Control (FCTC) of the WorldHealth Organization (WHO) becamebinding international law in February2005, it has already generated a largenumber of policy initiatives, which publichealth researchers have an obligation toensure are as effective as possible.Towards this end, a working groupformed by 26 scientists from nine coun-tries and the WHO, under the jointchairmanship of Ron Borland(Australia) and Mike Cummings (USA),met at the International Agency for
Cameroon: B&H stall
Cameroon: prize draw billboard
Australia: some of the outdated tobacco packsfound during ASH Australia’s survey.
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Research on Cancer (IARC) in Lyon,France, in March this year to outline acommon conceptual framework for theevaluation of FCTC tobacco control poli-cies, to guide assessments about whatpolicies work and why they work.
The result of their work, to be pub-lished next year as the 12th handbook inthe IARC Handbooks of Cancer Preventionseries, will provide a theory driven frame-work that IARC plans to apply in theevaluation of specific tobacco controlpolicy interventions.
As policies and the disseminated pro-grammes that result from policy decisionscan affect large numbers of people, insome cases the entire population, it isimportant to determine whether theyachieve their objectives, and do so in acost effective way with any incidentaleffects ideally having net benefits.
Four broad questions were considered,each with several more specific relatedquestions, to guide the review of thescientific literature on the methods andmeasures of tobacco policy evaluation.The broad questions cover how the effectsof a policy are determined; the coreconstructs for understanding how andwhy a given policy works; the potentialmoderator variables to consider whenevaluating a given policy; and the datasources that might be useful for evaluation.
The working group proposed a commonconceptual framework to guide futureFCTC policy evaluation, specifying twolevels of mediating variables: those spe-cific to the policy, and those that are partof more general pathways to the out-comes of interest. It also accepted thatvarious other factors (moderators) mightaffect the size of the effect, and recog-nised the possibility of effects incidentalto those an intervention is designed toproduce. The group concluded thattobacco use was the appropriate end pointfor most policy evaluations because bothprevention and cessation of tobacco usereduce tobacco related deaths and ill-nesses. The group elaborated the modelmost completely for tobacco use out-comes, but it was also applied to policiesaffecting product harmfulness.
For policies designed to affect tobaccouse, policy specific mediators involve suchelements such as awareness, policy spe-cific knowledge and reactions to specificelements of the intervention. For exam-ple, new graphic warning labels arepredicted to increase the salience andvisibility of warnings, and perhaps for-going of occasional cigarettes. Generalmediators are constructs taken frombehavioural science theory that we knowmediate the effects of such things asknowledge and awareness on behaviour,in this case tobacco use. They include
attitudes, normative beliefs and inten-tions.
Moderator variables include those fac-tors that change the magnitude of theeffects of an intervention without neces-sarily being changed by the intervention.They often include sociodemographiccharacteristics (for example, age, gender,socioeconomic status, cultural back-ground) and psychological factors thatare either assumed to be stable or whichthe intervention is not designed to change(for example, level of dependence).
The handbook will include logic modelsoutlining relevant constructs for evaluat-ing the effectiveness of policies ontobacco taxation, smoke-free environ-ments, tobacco product regulations, limitson tobacco marketing communications,product labelling, anti-tobacco publiccommunication campaigns and tobaccouse cessation interventions. Additionally,it will provide examples of measures usedto assess key constructs, with specialattention to measurement issues withsurvey methods.
It will also include descriptions ofsources of data on tobacco control poli-cies, tobacco production and trade, andrepositories of youth and adult surveil-lance surveys. These sources of informa-tion are particularly important for makingcomparisons between countries, and insome cases can be used to demonstratethe impact of policies, although not themechanisms by which they occur. Lastly,the volume will present the terminologyto judge the quality of the evidenceconsidered in the evaluation of tobaccocontrol policies and to be used in futureIARC handbook publications.
The FCTC has propelled tobacco controlinto a new era as countries all over theworld incorporate its policies and recom-mendations into their own laws. Astobacco control policies are formulatedand implemented, it is important thatthey undergo rigorous evaluation. In thesame way that evidence based medicinehas been built from rigorous evaluation oftreatment options, evidence based publichealth must build on a database ofrigorous evaluations of public healthpolicies. Such knowledge will allowimplementation of the most powerfulpolicy interventions, and will do so inways that will maximise their effective-ness.
UK: FI promotion dead,but won’t lie downTobacco companies will keep testing whatthey can get away with in their efforts toattach the most persuasive images totheir cigarette brands, even in countrieswith total bans on promotion. If they
provide the means and rationale forpromotion, they can also rely on othersto do the same.
In recent months, a motorsports shopin Regent Street, at the very heart ofLondon’s west end shopping area, had awindow display of three mannequinsdressed in Formula One driving suits,two with Lucky Strike logos on the chest,and one in a Benson & Hedges suit, albeitwith new lettering used by B&H to getround the UK’s sponsorship restrictions.
In addition to the mannequins, therewere numerous examples of tobaccopromotion within the shop, such asmodel racing cars, drivers’ caps andpictures of motor racing events. Specifictobacco company logos featured on theproducts included Marlboro, Benson &Hedges and Camel.
Action on Smoking and Health (ASH)contacted local trading standards offi-cials, who acted quickly, ordering theshop to remove the tobacco sponsoredclothing within a week. ASH had lesssuccess with the other promotional itemsin the shop. It is highly likely that othershops around the UK are doing the samesort of thing, without a well informed andalert passer-by spotting and reportingthem. And if a majority of such promo-tions go unpunished, presumably theindustry will keep orchestrating or facil-itating them.
Belgium: ban failsentrance testBelgians are facing that classic problemafter a public places smoking ban: smoke
UK: mannequins dressed in Formula One drivingsuits promoting Lucky Strike and Benson &Hedges cigarettes, in a shop in London’s west endthis year.
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pollution at the entrances of buildings. Aparticularly unpleasant and inappropriatesituation was described recently by asmoking cessation counsellor at one ofthe country’s top teaching hospitals.Smoke from the many smokers packedinto the entrance area at any one time—staff, patients and visitors—and the massof litter they left behind, was not onlydenying other staff a smoke-free work-place, but was manifestly unpleasant forthe smokers themselves.
The counsellor suggested that thehospital set up a temporary smokingroom, coupled with the offer and provi-sion of cessation counselling for thosewho used it. Despite a promise that thesituation would be remedied—it had beenthe subject of other complaints—it tookadverse publicity in a national newspaperto produce action. The hospital authori-ties announced a separate area for
smokers, though there was no mentionof linking this with cessation services.
Clearly, such a measure must only be aninterim stage on the way to a completelysmoke-free environment. It illustrates thedifficulties that many countries face, espe-cially if there has not been steady prepara-tion over many years, using publicinformation and education campaigns, tocreate a genuinely smoke-free culture.
North Korea: singularaim of smoking banWe all know of countries that owe theirsmoking bans mainly to one individual. Itis usually a health minister, often aphysician who has seen all too much ofthe clinical results of smoking, whopersuades fellow ministers to back atobacco control bill, and has the dedica-tion, political skills and courage, not to
mention the energy to see it through theinevitable media and parliamentarystorms thrown up by tobacco interestsbefore it finally becomes law. NorthKorea now has a smoking ban, notmainly but entirely due to the influenceof one individual, and not for the usualreasons. Although detailed informationdoes not flow too easily from theDemocratic People’s Republic of Korea,as it is officially called, it has beenreported that doctors recommended topresident Kim Jong-il that he stop smok-ing (as well as drinking alcohol) andarrange to live and work in a totallysmoke-free environment. Thus the home,office and everywhere else visited by KimJong-Il, chairman of the national defencecommission, supreme commander of theKorean people’s army and general secre-tary of the workers’ party of Korea, havebeen made smoke free.
The Lighter Side......................................................................................
E O’Farrell, Illawara Mercury.
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