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Summer 2000, MONITOR 1

MONIT RSummer 2000 Vol. 8, Issue 2

Global Health & Environment

See Bangladesh, page 6

New Tobacco Control Era Dawns

by Debra Efroymson, Regional Advisor, PATH Canada, Dhaka, BangladeshBATA Battles BAT In Bangladesh

Global Tobacco Trends Spark Hope, Sound Alarmby Michael Eriksen, ScD; Lawrence Green, DrPH; Linda Bailey, JD, MHS; Terry Pechacek, PhD, Office on Smoking and Health,Centers for Disease Control and Prevention, U.S. Department of Health and Human Services

See Global Trends, page 2

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Tobacco control is heralded asone of the 10 greatest publichealth achievements of the 20th cen-

tury in the United States. This recognitionreflects the dramatic reduction of smokingprevalence among U.S. adults from 42.4percent in 1965 to 24.7 percent in 1997.But just as the United States, Canada,Australia, New Zealand and several Euro-pean countries were dramatically reducingtheir tobacco consumption, the develop-ing world faced a tobacco epidemic. Whatdoes experience tell us about effectivetobacco control strategies for the future?

Industrialized Nations ShowHopeful SignsEffective programs as well as supportivepublic policies are needed to curtail to-bacco use. The positive trends in U.S.smoking prevalence have resulted not sim-ply from scientific knowledge that tobaccouse and environmental exposure to tobaccoare hazardous to health, but from a combi-

nation of public education, advocacy fornonsmokers’ rights, restrictions on ciga-rette advertising, improvements in treat-ment and prevention programs, and an im-proved understanding of the economic costs

of tobacco. Publicpolicy advances (seechart) have also con-tributed to the reduc-tions; and legislationrestricting smoking inpublic places, in-creased taxation andenforcement of mi-nors’ access laws havemade a substantial im-pact. And now, thedisclosure of tobaccoindustry documentsprovides opportuni-ties for a new ap-proach to tobaccocontrol programs andpolicies – actions that

address corporate intent to confuse, mis-lead, and obfuscate the public’s under-standing of the harm caused by smoking.

With a population of about 123million, Bangladesh is oneof the poorest and most densely

populated countries in the world. Nearlyhalf the population lives below the pov-erty line. And while life expectancy hasincreased over the past decade, it stands at60.5 for women and 60.7 for men, withdiarrhea, cardiovascular diseases and asthmathe top three causes of death.

Tobacco vs. Food ConsumptionTobacco use has not been well-monitored inBangladesh. The latest large survey appearsto simply study smoking, ignoring the hugeissue of smokeless tobacco use. Smokingrates are much higher in men (43.8%) thanin women (4.6%), with men aged 35 to 49having the highest rate – 66.1 percent. And,the economic burden of tobacco inBangladesh is substantial.

In 1996, average yearly expenditure onfood for men and women, was just 2.4 timeswhat they spent on tobacco in 1997. Menwho smoke cigarettes (rather than cheaperforms of tobacco) spend nearly as much oncigarettes as on food. Since about half thepopulation is malnourished and a large por-tion of spending goes to food, it is clear thatreducing tobacco use could hugely benefitnutritional status.

John Player GOLD LEAF posters adorn a run-down shop-front in Comilla, Bangladesh

The Industry’s AgendaBangladesh is home to several local tobaccocompanies. In 1998, the Bangladesh To-bacco Company was bought out by British

Inside Issues• Insider’s View 3• European Advances 4, 5• Industry Secrets 6• FCTC 7• Policy Matters 8

2 MONITOR, Summer 2000

Continued from page 1

. . .Global Trends

-Sushma Palmer, D.Sc.,Chairman

CECheck-UpDeveloping Country Trends SignalAlarmAs tobacco control programs and policiessucceed – and sales plummet – in industri-alized nations, the tobacco epidemic isaggressively spreading into developing coun-tries. The World Health Organization(WHO) currently estimates that about 1.15billion smokers in the world consume anaverage of 14 cigarettes each per day. Ofthese, 82 percent live in low- and middle-income countries. Such patterns of tobaccoconsumption will have devastating effectson future global health: 10 million peoplewill die annually – 11,000 deaths per day –from tobacco-attributed diseases by thelate 2020s. In short, tobacco will overtakethe pandemics of the present and past as theleading cause of death in developing coun-tries.

Many developing countries face criticalbarriers to tobacco control. First, tobaccoconsumption, in parallel with per capitaincome, is growing in developing countries.Second, the citizens of developing coun-tries are less exposed to education on thehealth hazards of smoking and, therefore,are less inclined to treat tobacco as a signifi-cant threat. Third, many developing coun-tries still suffer from a heavy burden ofinfectious diseases and malnutrition andaccord a lower priority to tobacco-relatedhealth effects. Fourth, and perhaps fore-most, many developing countries have yetto assemble the political will needed toenforce measures that treat tobacco com-mensurate with the harm that it causes. Inmany, the government is tempted by the“smoke ring” of tobacco – specifically em-ployment, revenue and trade. Tobaccomarketing is costly in the long run, experi-ence tells us. In California, data show thatfor every dollar spent on tobacco control,the state realized a savings of $1.50 in directmedical services and $4 in the overall costof tobacco-associated illnesses.

Effective Strategies Spell EffectiveControlWorld Bank economists recognize that thepublic health benefits of tobacco control farexceed the costs, and price increases are themost effective strategy for reducing de-mand for tobacco products both in indus-trialized and in low- and middle-incomecountries. Mostly implemented throughexcise taxes, price increases reduce smok-ing, especially among youth. World Bankstudies show that temporary income lossamong producers and distributors may beone consequence, but without a dramaticneed for downsizing. Furthermore, theimpact of price increases may be signifi-cantly enhanced by measures that ban orrestrict tobacco advertising and promotion

“We’ve come a long way, VirginiaSlims!”…quips veteran anti-tobacco ad-vocate David Simpson in this issue’s“Insider’s View” as he recounts thetobacco control movement over thedecades.

In view of the upcoming 11th WorldConference on Tobacco or Health inChicago, this Global Health and Envi-ronment Monitor relates the personalstories and official accounts of certainkey people and organizations that havebeen facing major challenges, fightingthe tobacco wars and making unprec-edented advances. Simultaneously,the issue points to the growing menaceof tobacco—especially in the develop-ing world in women and children – themost vulnerable to its hazards.

Michael Erickson and colleagues fromCDC lead off with a global dichotomy—progress in the industrialized world,contrasted with the looming epidemic indeveloping nations, which are leastprepared to cope with the challenge,economically or technically. A starkexample of the dilemma is shown byDebra Efroymson’s review of the foodvs. tobacco struggle in Bangladesh.The Centerfold, effectively covered byWitold Zatonski, Sibylle Fleitman andHungary’s Zuzanna Furesi et. al, high-lights European achievements andchallenges, in the East and West. Itincludes Beverly Jensen’s update ofCECHE’s World Bank-supported projecton tobacco control in the Czech Repub-lic, with the Internet at its service.

Replacing CECHE In The News, justthis time, are two crucial matters—thecache of tobacco industry documents,dissected by Norbert Hirschorn, andWHO’s Framework Convention on To-bacco Control, summarized by DouglasBettcher and colleagues from WHO.

The issue concludes with Dr. JudithMackay from China, who gently re-minds us that the tobacco control poli-cies of today may have their origin in the1600s. She highlights the fact thatWHO is finally (my emphasis!) taking itsrightful place at the head of the table insetting the global tobacco policyagenda in the new millennium. That byitself is cause for celebration at the 11thWorld Conference in Chicago!

See you there!

or increase public awareness of tobacco’sharm. For example, cigarette labels maycontain prominent health warnings and listingredients or levels of tars, nicotine andother harmful constituents. In Sweden,Iceland, Norway and Canada, pictures areused or proposed to increase the impact ofsuch warnings.

Nicotine replacement therapy and othercessation interventions are also effectivedemand-reduction tools. In the UnitedStates, proposals are being considered tomandate Medicaid coverage of both pre-scription and non-prescription smokingcessation drugs, removing current exclu-sions in the law. Private insurers andmanaged care organizations are making simi-lar commitments to helping smokers quit.

The recent World Bank report “Curbingthe Epidemic” concludes that supply re-duction is a less promising approach totobacco control. Some attention to suchpolicies, nevertheless, is warranted. Forexample, smuggling becomes a concern whenneighboring areas experience cost differen-tials (i.e., in border areas and special juris-dictions such as military bases and tribalreservations). Measures such as moreprominent tax stamps and aggressive en-forcement and prosecution can be effectivein preventing smuggling. Indeed, tradepolicies and tobacco control should becomplementary. The U.S. Congress re-cently prohibited the expenditure of taxdollars to support the export and promo-tion of cigarettes, and U.S. diplomatic postsare now directed to assist tobacco controlefforts in host countries.

At the global level, in 1996, WHO mem-ber states initiated a Framework Conven-tion on Tobacco Control (FCTC), a legalinstrument intended to address the globalproblem of tobacco use. Once adopted byWHO, the convention and related proto-cols will be subject to ratification by mem-ber states. (See WHO...p.7. Also, visit:WHO’s website, http://www.who.int/toh/fctc/fctcintro.htm; and the U.S. Govern-ment site, http://www.cdc.gov/tobacco.)

Non-governmental organizations, re-search institutes and professional associa-tions also play a critical role in the develop-ment of tobacco control programs and poli-cies through their domestic and interna-tional activities. For the FCTC, these groupsare essential. The U.S. Government will callon such partners to participate in the devel-opment and ratification of the FCTC andthe implementation of subsequent bilateraland multilateral protocols. The success ofthese multiple intervention strategies willreshape the tobacco control landscapeworldwide for the year 2003 and beyond.§Michele Chang of CDC contributed to thisarticle.


Insider’s View

Amonth after starting work in to-bacco control in 1979, I attendedthe 4th World Conference on To-

bacco and Health in Stockholm. Tobaccowas already a massive health problem, fastspreading to developing countries, but boththe agenda and the attendance were limitedby today’s standards. Taxation, for example– now shown to be one of the most effectivetools for reducing tobacco consumption –was hardly featured; and the vast majority ofdelegates were from Europe and NorthAmerica – as we were still talking of“tomorrow’s epidemic” for developing coun-tries, and the overwhelming disparity ofpower and perceived importance of the to-bacco industry ruled out any hope of asolution.

Looking BackTwo memorable speakers in Stockholm werepoliticians whose subsequent careers neatlydemonstrated why the ephemeral nature ofpolitics could not be trusted to deliver aneasy, fail-safe solution. Then U.S. Secretaryfor Health Joseph Califano gave a superb andfiery talk, leaving delegates excited that hereat last was the U.S. cavalry riding to therescue. His British counterpart, Sir GeorgeYoung, gave an equally inspiring perfor-mance, stating that “For prospective pa-tients, the answer may not be incision at theoperating table, but prevention by decisionat the cabinet table.” Califano left in triumphfor a visit to China, but before he got homewas sacked from President Carter’s cabinet.Political commentators rated his strong standon tobacco the major factor in his dismissal.Someone coined the term “MyoCalifanoInfarction” (MoI): the sudden cutting-off ofpolitical life caused by being tough on to-bacco. Sir George Young suffered an MoItwo years later.

Also in Stockholm was a tobacco indus-try delegation. A memo written by one ofthem and later leaked to the press claimed,“The social acceptability issue will be thecentral battleground on which our case in thelong run will be lost or won.” In those daysresearch showed that, except to infants andangina sufferers, passive smoking posed noharm. The valuable insight into industryperceptions showed the importance of mak-ing non-smoking regulation a priority, a pointeffectively grasped by nongovernmentalorganisations (NGOs) in the United States asevidence of the serious risk of disease to non-smokers began to accumulate in the 1980s.

Where Are We Now?

We’ve Come A Long Way, Virginia Slims!by David Simpson, Director, International Agency on Tobacco and Health, United Kingdom

David Simpsonaddresses the 2ndWorld Conference onCancer Organizations,Atlanta, GA

tobacco markets, apart from China, are domi-nated by two giants whose annual salesdwarf the entire economic activity of manydeveloping countries. By stealth and jointventure agreements, they have even invadedChina, the biggest market of all. In Stockholm,we gasped at the crude cynicism of contem-porary cigarette advertising by Western com-panies in Africa. Now, their subsidiaries indeveloping countries have wound down sup-port for local products in favour of “interna-tional” brands – thanks to increasingly globalnews media. Industry sponsorship of sportsand cultural events, virtually unknown in

developing countries in 1979, is now asubiquitous and serious a problem there as inthe industrialised world.

Another important change is litigation.Tobacco companies have realised they havenothing to lose (and virtually limitless re-sources to burn) by taking legal action as faras it can go to challenge public health mea-sures. They destroyed Canada’s first com-prehensive legislation, considered the best inthe world; they stopped the U.S. Food andDrug Administration from using its powersto regulate tobacco, a dangerous drug if everthere was one; and they now routinely andboldly pursue legal action against govern-ments and NGOs alike. The disruption tonormal life and the massive legal costs arestrong deterrents against fighting back.

Ironically, litigation has been a majorbenefit to health. If information is the mainammunition which our troops use in thetobacco war, the millions of incriminatingindustry documents forced into the public

domain by trials in Minnesota and elsewherein the United States represent a cache whosefirepower would have seemed the stuff offantasy 20 years ago. (See Industry...p.6.)The enemy does not obey normal rules,however, and while embarrassed into declar-ing itself reformed in the West, it shows nohint of changing its practices in developingcountries.

Cause To CelebrateDespite the industry’s might and ruthless-ness, there is much to celebrate. A trulyinternational tobacco control movement nowexists, and, thanks to the pioneering effortsof NGOs, the concept of tobacco control hasbeen established as a legitimate issue in everycountry. Twenty years ago only a minorityof cancer, heart and lung associations hadprogrammes on tobacco; nowadays few suchNGOs ignore the issue. In fact, many haveprogrammes far outstripping the efforts oftheir governments. My own organisationserves around 200 tobacco control advocatesin 108 developing nations – but we knowthey are a minority of those now active in thedeveloping world. Better still, as the storyabout Bangladesh (see p.1) demonstrates,such advocates are networking and formingthe coalitions so essential for success.

Tobacco control workers are networkinginternationally, too. The ability of an advo-cate to put an appeal on GLOBALink andreceive active help within hours from everycorner of the world must rate as one of themost significant improvements of all. Twentyyears ago, this would have seemed a crazydream.

Changes at WHO (which previously saidthe right things but had neither the resourcesnor the political backing to deliver on them)have raised the profile of tobacco control onthe political agenda. WHO’s flagship Frame-work Convention on Tobacco Control (seeWHO...p.7) has already achieved the mostimportant evaluation of its likely success:the desperate condemnation of the tobaccoindustry.

We are in the best shape ever for winningthe war, but millions will die, many battleswill be fought, and a long, hard campaign willbe waged before we do.§

What are the most striking changes sincethose early days? First, the big transnationaltobacco companies have become even big-ger, swallowing each other until the world’s

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Swedish doctors march in support of the SwedishTobacco Act of 1993.


by Prof. Witold Zatonski, Marie Curie Cancer Center, Warsaw, Poland

Before World War II, Eastern European countries consumed littletobacco. After the war, cigarettes became a symbol of development,widely available and very cheap. Smoking among Eastern European

men rose dramatically and became so widespread that in the mid-’70s onlyabout 10 percent of adult men had never smoked. Smoking was less prevalentamong women, especially among older and rural female inhabitants.

Dismal PastAt the dawn of the 1990s, Eastern European males had the highest level oftobacco-dependent disease in the world, WHO estimated. Nearly everysecond premature death in middle-aged men could be traced to tobacco smoke,and an unprecedented 60 percent of all cancers in young adult and middle-agedmen was connected to smoking. Following the political and economic changesof the mid-’90s, smoking patterns became heterogeneous across the region.In some countries, tobacco sales are no longer rising. In Poland, they havefallen 10 percent in the last decade. In the former Soviet Union and othercountries with especially difficult transitions, the number of male smokersremains stagnant. Meanwhile, tobacco use is rising among women, especiallyyoung women, throughout the region (excluding Poland).

Tobacco Control Gains Groundin Eastern Europe

Recent SuccessIn the face of these challenges, upon Poland’s return to democracy, a health lobbywas established to support comprehensive tobacco control. Its work resulted in the1995 “Law on the Protection of Public Health against the Effects of Tobacco Use.”Updated in 1999, this law aimed to create conditions (education, economic conditions,laws and addiction treatment) to limit the health effects of smoking. Its mostimportant provisions are:

1. A ban on radio, television and some print advertising of tobacco until2000 (A total ban on advertising, sponsorship and donations to politicalparties by tobacco companies was added in 1999 and will be implementedin 2001.)

2. A ban on the sale of tobacco products to minors (<18 years)3. A ban on cigarette vending machines and loose cigarette sales4. A ban on smoking in schools, health care facilities and enclosed workplaces,

except in designated areas5. Health warnings on advertising and cigarette packs covering the top 20

percent of the advertisement and 30 percent of a cigarette pack6. The creation of a fund for tobacco control activities, consisting of 0.5

percent of the excise taxes collected from cigarette sales (added in 1999).This law, coupled with Poland’s “Gold Standard” tobacco control program, has

produced some encouraging results. Cigarette sales fell by 10 percent from 1990 to1998, and smoking rates have fallen, with the ranks of ex-smokers growing. Decreasingexposure to tobacco has meant better health indicators. Lung cancer, a disease seenalmost exclusively in smokers, has been declining among young and middle-aged menin Poland for some time. Nevertheless, youth, especially girls, are smoking more andlighting up younger. And while tobacco control programs are now focusing onsmokers most physically and psychologically addicted to their habit, most health careproviders are still not familiar with treating nicotine addiction.

Hopeful FutureThankfully, networks of tobacco control advocates in Central and Eastern Europeare growing. Efforts and government support vary significantly around the region,with anti-tobacco advocates ranging from health ministry workers to church leaders;but increased Internet access has allowed GLOBALink membership and access toimportant data, and Eastern Europeans are increasingly participating in internationalconferences.

Countries like Poland and the Czech Republic have developed health strategiesand monitoring agencies, but many others are just beginning tobacco control effortsand have few policies promoting health. In these nations, basic health informationmay not be available; most health care systems do not offer nicotine replacementtherapy; and many health care workers are not trained in treating nicotine addiction(and smoke more than the average person). In some places, smoking is culturallyembedded, and the price of cigarettes is relatively low, with multinational tobaccocompanies eagerly exploiting these factors.

Progress is not impossible, however. Reducing smoking requires concerted effortby medical professionals, scientists, politicians, teachers and parents. It also requiresinternational solidarity.§

Hungarians are relatively prolific—and tolerant— when it comes tosmoking. So reveals a survey of Hungarian smoking (and drinking)habits commissioned by the National Institute for Health Promotion

in Budapest and conducted in fall 1999 by the Pecs-based Fact Institute ofApplied Social Sciences Research.

This survey of a representative national sample of 1200 Hungarian adultsfound that 41 percent of the respondents smoked more or less regularly, with32 percent smoking daily and 9 percent occasionally. Smoking is alsopredominantly a male habit in Hungary as elsewhere: 44 percent of malesand 21 percent of females said they smoke every day.

While the majority agreed that “Smoking can cause serious diseases”, 41percent believed this applied only to excessive smoking. (Respondents witha family history of smoking-related conditions agreed that smoking can causeserious diseases, whether or not it is excessive.) A considerably lowerpercentage—38 versus 56 percent— agreed that “Drinking can cause seriousdiseases.” The majority, 56 percent, said they are not disturbed by otherssmoking in their presence, underlining the social acceptance of smoking inHungary. Nevertheless, 70 percent agreed that inhaling the smoke of othersis a health risk.

Tobacco control measures received respondents’ overall support, butabout half of those who supported smoking restrictions believe the restric-tions will not be observed. Meanwhile, about 75 percent of respondents labelefforts of health care institutions to restrict smoking as unsatisfactory; andone-third expressed the opinion that doctors and other members of themedical profession are not interested in the problem.

A substantial majority, 67 percent, believe that tobacco manufacturersare not responsible for distributing hazardous products, because nobodyforces smokers to consume the products. And while 29 percent claimed thattobacco manufacturers could be sued in Hungary, less than half the respon-dents ( 45%) are aware of similar suits in other countries. Ironically, only15 percent said that they think the government does its best to curb smoking.§

by Zsuzsanna Fuzesi, MD, Ph.D, Laszlo Tistyan, MA, Monika Tarnok,Fact Institute of Applied Social Sciences Research, Pecs, Hungary

Hungarians Speak Out on Smoking andBig Tobacco

L&M’s promise “Discover the taste of freedom”countered by Polish Ministry of Health warning above“Smoking causes heart disease and cancer”

PALENIE TYTONIU POWODUJE RAKA I CHOROBY SERCAMinister Zdrowia i Opieki Spotecznej

EUROPE MARKS ADVANCES—


Source: Commission of the European Communities

EU Network Promotes Cross-Border Alliances Against Tobaccoby Sibylle Fleitmann, Secretary General, European Network for Smoking Prevention, Brussels

Created in 1957 among five member states as a supranational legislativebody to establish a European economic trade zone, the European Union(EU) today comprises 15 member states that are moving towards a united

front against the threat of tobacco. The 550,000 annual tobacco-related deaths in the EU make smoking one of

its leading causes of morbidity and mortality. (See table.) Between 1987/88 and1994/95, the average smoking rates decreased from 44 to 40 percent in men andfrom 28 to 27 percent in women (thanks in part to the Europe Against CancerProgramme created by the heads of state of the EU in 1987). However, the latest

surveys show thatthe prevalence ofsmoking in womenis rising in severalEU countries. Inmost, smokingamong youngstersis also increasing,with girls smok-ing slightly morethan boys.Cross-BorderCo-operationCollaboration ontobacco controlissues on the Eu-ropean level beganin 1987 when theCommission ofthe EuropeanUnion formed aworking group of

organisations representing national tobacco control activities. The goal was topromote cross-border cooperation aimed at decreasing smoking-related cancermortality. Between 1987 and 1996, the EU promoted various projects to increasethe efficiency and coherence of smoking prevention activities and programs. Onemilestone was the creation in 1988 of European Bureau for Action on SmokingPrevention (BASP), which assisted the EU Commission on information collec-tion and dissemination. With the support of BASP, several theme-based cross-border networks emerged, including the European Network on Young People andTobacco (ENYPAT) and a European Smoke-Free Cities Network.

Common goals for increased collaboration, adopted in 1994, encompassed thecreation of a permanent pan-European tobacco control structure and theestablishment of national coalitions to promote a coordinated approach totobacco control at a country level. It took three years, several meetings and theEU’s threats to abandon its financial support before agreement could be reachedamong nongovernmental organizations (NGOs) to create a coordinating body fortobacco control — the European Network for Smoking Prevention (ENSP).Building national coalitions proved more difficult, plagued by lack of knowledgeof ongoing activities, fear of competition and divergent political interests. Forexample, of the four kinds of organisations involved in tobacco control in Europein 1996, professional associations generally favored a more aggressive approachtowards policy reform, whereas cancer leagues, hospitals, universities and publichealth institutes preferred the public health model of smoking prevention.Fortunately, these groups put aside their differences and recognized that acoalition meant enhanced capacity for lobbying and advocacy towards establish-ing a legal framework for tobacco control on both a national and a European level.

Today, more than 350 organisations work with the ENSP through nationalcoalitions representing the 15 EU member states, Norway, Poland, Estonia,Hungary and the Czech Republic. New theme-based networks such as Interna-

Czechs, CECHE Launch Internet Network

On 19 April and 12 June, tobacco control advocates from bothsides of the Atlantic descended upon Podebrady, a resort townon the outskirts of Prague. Their two-fold mission: develop

practical strategies to motivate the Czech news media to circulate morestories on tobacco control, and encourage Czech policy-makers to under-take tobacco control reform.

These topics were the subject of a Media Relations Workshop and aPolicy Advocacy Workshop— planned for Czech health professionalsfrom government hygiene stations, nongovernmental organizations (NGOs)and international public health groups. (A workshop in October 1999 inPrague addressed Internet skills and featured hands-on training in informa-tion technology and electronic networking by CECHE partner Ruben Israelof GLOBALink.) These workshops in part mean a new approach tocountering smoking and its adverse consequences on cardiovascular disease(CVD) mortality in the Czech Republic.

In fact, it was the high prevalence of smoking in Czech men (40%) andwomen (30%) that prompted U.S.-based CECHE and Czech partners tolaunch an 18-month Internet-based demonstration initiative, the CzechTobacco-Control Training and Communications Program (TOB-CCP), in1999. The resulting electronic network, now 42 strong, will seek to ally withthe soon-to-be-formed CVD prevention-oriented NGO, The Czech HeartAssociation, in a population-based tobacco control program that will usethe Internet, working with Czech District Hygiene Stations and NGOs.

Meanwhile, experts in information technology and tobacco controlfrom the Czech Republic, other European countries and North America arepartnering in this effort to build indigenous capacity, heighten publicawareness, catalyze the creation of a tobacco-free environment in the CzechRepublic and explore the potential of the TOB-CCP to serve as a modelin other Central and Eastern European countries, and around the globe. §

by, Beverly Jensen, Senior Project Consultant, Center for Communications, Healthand the Environment (CECHE), Washington, DC

—NEW STRUGGLES LIE AHEAD

tional Network of Women Against Tobacco (INWAT) - Europe and theSmoke-Free Hospitals Network have joined ENSP, and close collaboration hasdeveloped with existing public health-oriented networks on both a Europeanand an international level.

Policies and ProgramsENSP’s main aim is to increase networking among NGOs across Europe. In1999 alone, ENSP succeeded in creating partnerships among 97 organizationsfrom 15 EU member states, plus Norway, Iceland and Romania, for 10 projectproposals amounting to about 3 million EURO. In fact, the ENSP has beenamong the leading forces behind a number of coordinated tobacco controlactivities. For instance, organized European lobbying campaigns led by UICC/ECL (the Asssociation of European Cancer Leagues) together with nationalcoalitions and networks were instrumental in the 1998 adoption of the EUdirective banning advertising in the 15 member states. Similar campaigns areunderway to support a proposed EU directive on tobacco product regulation.

On the international policy level, ENSP is actively working to generatesupport for the World Health Organization’s Framework Convention forTobacco Control through the Committee for a Tobacco-Free Europe (set upby WHO Europe) and the International Framework Convention Alliance.

Networking between advocacy-oriented coalitions and scientific networksin Europe is increasingly pragmatic and mutually beneficial. The challenge nowis to increase public participation in EU decision-making and thereby balancethe economic interests and the quality of life of the European citizen.§


Tobacco Industry Documents — Secrets Revealed

Those who saw the movie“The Insider” can appreci-ate just how recently we’ve discovered

what the tobacco industry kept hidden fordecades. A few industry secrets emerged fromtime to time in lawsuits, but hardly anyoneoutside the companies realized what the in-dustry knew about its product — yet deniedor refused to reveal in public. It is now obviousthat the tobacco industry knew the healthconsequences of tobacco, and that it knew thatnicotine worked as an addictive drug andmanipulated it to increase addiction. Internalindustry documents also reveal that the com-panies deliberately marketed to children, clan-destinely recruited and paid consultants, sci-entists and journalists to front the industry’scase, and even conspired in smuggling.

In 1994, the first major cache of docu-ments, from Brown and Williamson, was sentby a paralegal “whistle blower” to Prof. StantonGlantz at the University of California SanFrancisco (UCSF). Within a year, Glantz andhis colleagues published five articles in theJournal of the American Medical Association(JAMA) exposing the shocking collection.(Recall what Brown and Williamson was do-ing to “The Insider” Jeffrey Wigand and CBSat this time, and one must admire the courageof the Glantz team, JAMA editors and UCSF.)

Industry documents became publicly avail-able in May 1998 after an intense legal battlethat reached the U.S. Supreme Court. Insettling the case, which involved the State ofMinnesota suing the five U.S.-based cigarettecompanies and two affiliated agencies forconsumer fraud, the tobacco industry wasforced to release approximately 5 milliondocuments – some 34 million pages datingfrom the mid-1950s to 1994 – for storage inwarehouses in Minneapolis and Guildford,England. The agreement also stipulated (andwas reinforced by the 1998 “Master Settle-ment Agreement” with U.S. attorneys gen-eral) that all additional documents discoveredin succeeding lawsuits would be maintainedby the U.S. industry on websites and in thetwo warehouses until June 30, 2010.

The documents may be found electroni-cally through two principal Internet portals:one maintained by the tobacco companies,<www.tobaccoarchive.com>, and one by theU.S. Centers for Disease Control,<www.cdc.gov/tobacco/industrydocs>. Ac-cess to the paper documents stored in Minne-sota is easy, as the warehouse is managed bya legal services firm; access to the Guildfordwarehouse, controlled by British AmericanTobacco, is more difficult.

An international document research net-work has evolved since 1998 and includesacademics, journalists, tobacco control activ-

by Norbert Hirschhorn, M.D., Consultant,World Health Organization

Industry

American Tobacco (BAT), creating a prolifera-tion of highly promoted BAT products. Whilecigarette imports have historically been bannedin Bangladesh, an exception was made a fewyears ago for Benson & Hedges, and otherimported brands are widely available throughsmuggling. And, while tobacco ads are banned onelectronic media, they are ubiquitous on bill-boards, in newspapers, as handbills, and asbanners advertising a free cigarette for eachempty pack. In addition, Bangladesh is floodedwith Bengali-language tobacco ads on varioussatellite TV stations originating in India.

BAT – essentially the only transnationaloperating in Bangladesh – both widely promotescigarettes and attempts to portray a positiveimage through activities such as donating treeseedlings and sponsoring benefit concerts for

ists, lawyers and government officials. Theirefforts have resulted in numerous collec-tions of documents covering a range oftobacco-related topics. Based on thesecollections, nearly two dozen analyses ofindustry secrets have been published —and more are on the way. The most reveal-ing are referenced below.

By court order the documents comeonly from companies doing business in theUnited States, but since these companiesare transnational corporations, thousandsof the documents specifically relate to othernations and global regions. In fact, re-searchers are starting to assemble nationaland regional collections covering Asia, Eu-rope, Australia and the Middle East. Inaddition, a “second generation” of discov-ered documents begins to show how thetobacco industry has tried to subvert re-search proving the ill-effects of passivesmoke on non-smokers.

The tobacco industry keeps claimingthat tobacco use is an adult’s “informed”choice. The documents here, in the ware-houses and on the Web disclose how reso-lutely the industry fought to keep thepublic ignorant of the truth.

1. Glantz SA, Slade J, Bero LA, Hanauer P, Barnes DE, “TheCigarette Papers,” Berkeley:University of California Press,1996.2. Coughlin PJ, Janecek FJ, “A Review of R.J. Reynolds’Internal Documents Produced in Mangini vs. R.J. ReynoldsTobacco Company, Civil Number 939359 — The Case that Rid California and the American Landscape of “Joe Camel,”February 1998, <www.library.ucsf.edu/tobacco/mangini/report3. Hurt RD, Robertson CR, “Prying open the door to thetobacco industry’s secrets about nicotine,” JAMA1998;280:1173-81.4. ASH/UK, “Tobacco explained,” and “Big Tobacco andwomen,” 1998, <www.ash.org.uk>5. Cannon J, “The Y-1 papers,” 8 October 1998,<www.tobacco.org> [BAT’s use of high-nicotine variety to-bacco plants.]6. ASH (UK) and Imperial Cancer Research Fund, “The safercigarette: what the tobacco industry could do...and why ithasn’t done it. A survey of 25 years of patents for innovationsto reduce toxic and carcinogenic chemicals in tobacco smoke,”3 March 1999, <www.ash.org.uk/papers/patent.html>

7. Jarvis M, Bates C, “Why low tar cigarettes don’t work and how thetobacco industry has fooled the smoking public,” 18 March 1999,<www.ash.org.uk/papers/big-one.html>8. Bates C, Jarvis M, Connolly G, “Tobacco additives. Cigaretteengineering and nicotine addiction,” 14 July 1999, <www.ash.org.uk/papers/additives.html>9. Collishaw N, “Imperial Tobacco’s ‘elastic’ cigarettes,” Physiciansfor a Smoke-free Canada, 11 November 1999, <www.smoke-free.ca>10. Beelman MS, Ronderos MT, Schetzig EJ, “Major multinationalimplicated in cigarette smuggling, tax evasion, documents show (Part1 of 2).... Global reach of tobacco company’s involvement in cigarettesmuggling exposed in company papers (Part 2 of 2),” InternationalConsortium of Investigative Journalists of the Center for Public Integ-rity, 31 January, 2 February 2000, <www.icij.org>11. Perry CL, “The tobacco industry and underage youth smoking:Tobacco industry documents from the Minnesota litigation,” Archivesof Pediatric and Adolescent Medicine 1999;153:935-41.12. Leavell N-R, “The low tar lie,” Tobacco Control 1999;8:433-39.13. Ong EK, Glantz SA, “Tobacco industry efforts subverting theInternational Agency for Research on Cancer’s second-hand smokestudy,” Lancet 2000;355:1253-9.14. Hirschhorn N, “Shameful science: four decades of the Germantobacco industry’s hidden research on smoking and health,” TobaccoControl 2000, in press.15. Walsh B, Chapman S, “Eyes on the Prize: Transnational TobaccoCompanies in China 1976-1997,” Tobacco Control 2000, in press.16. Connolly GN, Wayne GD, Lymperis D, Doherty MC, “Howcigarette additives are used to mask environmental tobacco smoke,”submitted for publication.17. Muggli ME, Forster JL, Hurt RD, Repace JL, “ The Smoke YouDon’t See:Uncovering Tobacco Industry Strategies Aimed AgainstEnvironmental Tobacco Smoke,” submitted for publication.§


. . . Bangladesh

See Bangladesh, page 7


The Monitor is published by the:Center for Communications, Health, and theEnvironment (CECHE)4437 Reservoir Road, N.W.Washington, DC 20007Tel: (202) 965-5990, Fax: (202) 965-5996E-mail: [email protected] Site: http://www.ceche.org

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Editorial & DesignConsultant, Valeska StupakGraphic Artist, Kathy Lewis

charitable groups. It also engages in disinformationcampaigns. At a press conference in March2000, BAT claimed that there is no soundscientific evidence that tobacco causes seriousdisease.The Tobacco Control LandscapeFounded in 1997 to increase awareness of thedangers of smoking and prevent its spread,ADHUNIK has been Bangladesh’s lead organi-zation in tobacco control, holding the first na-tional seminar on tobacco in 1988. Listed amongADHUNIK’s early successes are the ban ontobacco advertising in electronic media, bans onsmoking on domestic flights, health warnings oncigarette packs and an increase in tobacco taxes.Other organizations, including the BangladeshCancer Society and the National Non-Smokers’Forum, advocated tobacco control in the 1980sand 1990s, but a shortage of resources limitedtheir capacity to influence government action.

The tobacco control movement in Bangladeshbegan in earnest in the fall of 1999 with theformation of the Bangladesh Anti-Tobacco Al-liance (BATA). BATA has 15 members, includ-ing health, anti-drug, women’s and developmentorganizations. The alliance meets regularly, andits successes include a January 2000 High Courtdirective requiring that the government pass aseries of tobacco control measures in Bangladesh.

Currently, BATA is drafting tobacco controllegislation for submission to the government,and it hopes to play a role in the enforcement of

Government

any legislation enacted. Key policies underreview are: putting stronger and larger warn-ings on cigarette packs; banning tobaccopromotion and sponsorship; and providingmore protection to non-smokers. BATAwill also lobby for higher taxes and for variousmeasures to ensure that the public – literateand illiterate – has sufficient knowledge tomake an informed choice about tobacco use.

But BATA faces manifold challenges. Asthe country’s single largest taxpayer, BAThas major influence on government action,whereas BATA has a minimal budget, no full-time staff and no office, and cannot afford themedia needed to reach a largely illiteratepopulation. (The adult literacy rate inBangladesh is 50.1 percent for men and 37.6percent for women.)

One key lesson from the Bangladeshiexperience is that networking among differ-ent organizations is highly effective. Byforming BATA and convening regular meet-ings, Bangladeshi nongovernmental organi-zations can now respond far more quicklyand effectively than in the past to actions oftobacco companies and to invitations fromthe government for participation. Whilecoalitions certainly have their problems, theycan make the difference between scatteredand largely ineffective efforts, and a massmovement capable of mobilizing the publicand politicians to control the tobacco epi-demic. BATA members hope that tobacco

consumption statistics in Bangladesh will soonreflect the growing importance being placed onsound policies and a strong tobacco controlmovement. §


. . . Bangladesh

WHO Unveils Framework Convention on Tobacco Control (FCTC)by Dr. Douglas Bettcher and Mr. William Onzivu, Tobacco Free Initiative, WHO, Geneva

Tobacco use kills 4 million people each year worldwide.The World Health Organization (WHO) estimates that, given current trends, by2030, tobacco-related diseases will cause 10 million deaths annually – with 70 percent of these deaths occurring in low- and middle-

income countries.On becoming director general of WHO in 1998, Dr. Gro Harlem Brundtland recognized that the tobacco epidemiccannot be halted by isolated efforts of governments, national nongovernmental organisations (NGOs) or

media advocates. This truly international problem requires an international response, she discerned,and designated WHO’s development of a Framework Convention on Tobacco Control (FCTC) and

related protocols a high-priority step to address this challenge.The FCTC’s success depends heavily on sustained political support from governments, global

institutions and society. In May 1999, WHO’s World Health Assembly established a workinggroup and an intergovernmental negotiating body to develop and negotiate the Framework

Convention. The first working-group meeting from 25-29 October 1999 inGeneva led to a series of broad draft elements and possible protocols for theproposed convention. Convening in Geneva from 27-29 March 2000, the

second working group elaborated on these proposals, identified areas of general agreement,and proposed options for consideration by the World Health Assembly and the intergovernmen-

tal negotiating body, which will meet for the first time this year in Geneva from 16-21 October. WHOmember states and observers, including NGOs, can participate in the negotiating body, whose role

is to draft and negotiate the FCTC and possible related protocols.Among the key issues to be addressed by the Framework Convention and future related protocols are: harmonisation

of tobacco prices; discontinuation of duty-free tobacco products; a possible ban on all advertisement and sponsorship; standardisation of testmethods; package design and labelling consonant with public health goals; elimination of subsidies for tobacco production; smuggling; andinformation sharing.

Experts worldwide agree that the central issue in tobacco control is demand reduction to promote public health goals; simultaneously, theyappreciate the need to attend to the social, economic and agricultural implications, even though these are long-term issues. Defining strategiesthat link the global and national dimensions of tobacco control is also important. Such strategies require concerted multisectoral initiatives– with NGOs such as CECHE acting as crucial catalysts both at the national and international levels to promote the development and successfulimplementation of the FCTC . §


Tobacco Control Policies Build on Centuries of WisdomPolicy Beat

by Dr. Judith Mackay, FRCP, Asian Consultancy on Tobacco Control, Hong Kong, China

The earliest recorded use of tobaccowas in America in the first centuryB.C.; but it was centuries later that

“tobacco control” began to surface. One ofthe first warnings came in the 1600s fromChinese philosopher Fang Yizhi, who saidthat prolonged smoking “scorches one’slung.”

The first tobacco control regulation wasissued in Bhutan in 1729, banning tobaccouse in all religious places. (It is still observedtoday.) In 1761, the first study on theharmful effects of tobacco took place inEngland. And, almost 200 years later, in the1950s, the new scientific era of investigationcommenced in England and the United States,followed in 1981 by the publication of thefirst major study on passive smoking byTakeshi Hirayama in Japan.

Tobacco Control Faces ChallengeDespite centuries of knowledge, decades ofaction, multiple World Health Assemblyresolutions and numerous global, regional,national and sub-national conferences, thenumber of tobacco users around the globe isincreasing, more children are becoming ad-dicted, more people are dying, and economiccosts are escalating. To boot, the epidemicis invading poorly prepared de-veloping countries, which by2030, will house 85 percent of theworld’s smokers.

More optimistically, the sys-tems that will eventually reducethis epidemic are being put intoplace around the world. In general,tobacco control in developed coun-tries is far ahead of that in devel-oping ones, but not uniformly so(see Global Trends...p. 1). Forexample, legislation in Singapore,Fiji, Hong Kong, Mongolia, SouthAfrica, Thailand and Vietnam isfar stronger than that in severalWestern countries.

The need for government lead-ership and tobacco control poli-cies is surprisingly similar world-wide. Even the challenges and obstacles arealike – the focus of health professionals oncurative medicine... the hesitation of govern-ments to act firmly...a preoccupation withother illnesses that cause far fewer deaths...lack of funds.

But the most formidable opposition isthe tobacco industry, whose global tacticsinclude employing powerful legal firms,public relations companies, lobbyists andfront groups to present their arguments,create and place advertising, and facilitatelucrative sponsorships. The industry alsorecruits scientists to challenge health facts,

funds officials and political parties, and arguesfor voluntary agreements instead of legislation.In addition, it attacks price increases, bans ontobacco promotion and the creation of smoke-free areas in public places – suggesting thatthese are highly effective measures. Con-versely, the industry ignores (or even sup-ports) health education in schools, health warn-ings, and bans on sales to minors, indicatingthat these are largely ineffective measures,albeit useful first-step actions for governmentsembarking on a tobacco control policy. Theindustry also invokes “freedom of choice”arguments to oppose restrictions on advertis-ing and marketing in places as diverse as SouthAfrica and Hong Kong.

Tobacco Control Benefits EconomiesThe tobacco industry warns that control mea-sures will damage the economy, cause joblosses and decrease tax revenue. In fact, to-bacco control measures are unlikely to hurtcurrent tobacco farmers, because any reduc-tion in tobacco consumption lies decades ahead,giving ample opportunity for an orderly reduc-tion in production. Other job and tax losses arealso unlikely, since when people don’t spendmoney on tobacco they spend it on other goodsand services. Conversely, if no action is taken,

WHO Leadsthe Way

...Heard on the Worldwide Web

millions of jobs will indeed be lost – by thesmokers who die each year, with economicconsequences for their families.

The 1999 World Bank report “Curbing theEpidemic” marks the first time a major financialinstitution has supported policies designed toreduce tobacco demand. The document arguesthat tobacco control is good for the wealth aswell as the health of nations; that it does not leadto loss of taxes or jobs; and that tobacco controlmeasures (e.g., price increases, advertising bans,smoke-free areas, health education and pharma-ceutical assistance in quitting) are cost-effectivein both industrialized and developing countries.

In 1998,WHO’s thennewly ap-pointed Direc-tor General Dr.Gro HarlemB r u n d t l a n dcreated theWHO To-bacco-Free Ini-tiative (TFI).The TFI has increased visibility, staffing andfunding for tobacco, and spawned new initia-tives relating to legislation, taxation youthprogrammes, media and nongovernmentalorganisation (NGO) advocacy. New part-nerships have been forged within WHO, andamong WHO and the World Bank, UNICEF,the International Monetary Fund, NGOs,women’s groups, the pharmaceutical indus-try and funding agencies.

Indeed, tobacco has been discussed byWHO at the highest levels – the World Eco-nomic Forum in Davos (1999) and the NinthInternational Conference of Drug RegulatoryAuthorities in Berlin (1999). Within theUnited Nations (UN), an Ad Hoc Intra-Agency Task Force On Tobacco Control hasbeen established. “Tobacco Control for Chinain the 21st Century,” a collaborative effort ofWHO, the World Bank, Centers for DiseaseControl, Health Canada and Johns HopkinsUniversity with the Chinese Ministry ofHealth and the Chinese Academy of Preven-tive Medicine, exemplifies country-level ac-tion. WHO’s proposed international Frame-work Convention on Tobacco Control(FCTC), which signifies the trans-bordercooperation required to address the globaltobacco epidemic, will be the organisation’sfirst convention and global agreement de-voted entirely to tobacco control within theUN system. (See WHO... p.7.)

Already, the tobacco industry has re-acted, arguing that “WHO is behaving like a‘super-nanny’... and will destroy the liveli-hoods of farmers in developing nations.” –good signs that the effort is working. Mean-while, the industry is trying to repositionitself to secure public support, responding toits tarnished image from exposure of internalindustry documents. (See Industry...p.6.)Until the industry acknowledges the healthhazards of tobacco, accepts regulation andceases to obstruct tobacco control measures,however, neither governments nor the publichealth community can risk industry involve-ment in policy making – in decisions thataffect the lives of millions and the future ofgenerations to come.§

0

0

0

1

1

1

1

1

2

2

2

Number ofSmokers

T obaccoDeaths,annual

C hildrenE xposed to

E T S**

E conomicC osts >

Losses, US

500 million

5 million

50 billion

2.0 billion

200 billion

10 million

1 billion

1.5 billion

THE GLOBAL TOBACCOEPIDEMIC: 2000-2030

2 0 3 02 0 3 02 0 3 02 0 3 02 0 3 0 *****

2030 ???2030 ???2030 ???2030 ???2030 ???

2 0 0 02 0 0 02 0 0 02 0 0 02 0 0 0

* Assuming current tobacco control trends continue**Environmental Tobacco Smoke

100 billion

700 million