News analysisNEW ZEALAND: INDUSTRY FACES GRILLINGOVER MAORISIn which country might one hear themost refreshingly straight talk about thetobacco industry in the national legisla-ture? There may be no easy, singleanswer, but recent experience suggeststhat New Zealand must be a contender.

While the majority of New Zealandershave been reducing their tobacco con-sumption for several decades, the indigen-ous Maori people still have alarminglyhigh smoking rates. New data announcedby the health ministry in Septembershowed that 49.3 per cent of Maoriwomen and 41.5 per cent of Maori menstill smoke, compared to just over a fifthof the adult population as a whole. Likemany countries with a relatively longhistory of public education about tobacco,it is among the lower income, morevulnerable minority population wheretobacco companies see their greatesthopes of sustaining sales.

Not surprisingly, then, Mr HoneHarawira, a member of parliament forthe Maori Party, wants tobacco companyexecutives to be summoned personally toface questions at an inquiry by the MaoriAffairs parliamentary select committeeinto the impact of tobacco use on Maoripeople. The committee would talk toeverybody concerned, he said, before itgot to the tobacco companies, implyingthat he was determined that the fullestpowers available to the parliament’sSpeaker be used to force the NewZealand-based chairpersons and chiefexecutives, not just the public relations‘‘spin doctors’’, to be involved.

Mr Harawira made it plain that heexpected this to be an uncomfortableexperience for those involved. Just in caseanyone missed any slight nuance ofmeaning in his announcement, he added:‘‘to be brutally frank I’d like to lynchthese bastards... This is a war againstpeople who kill New Zealanders ... I don’tparticularly give a shit about what theysay [in their defence].’’

URUGUAY: NEW HEALTH WARNINGSUruguay is set to have the largest healthwarnings in the world. A new set of sixgraphic pack warnings, each covering 80per cent of the front and back of the pack,was finalised in September. They willhave to be in place by 1 March 2010,though the warnings they replace, whichcovered 50 per cent of the pack, wereordered to be expanded to 80 per cent byDecember. The two large sides of the packare not the only place where Uruguayansmokers will see health warning informa-tion: a statement will also be required onthe side of tobacco packages, in black onwhite, to the effect that the productinside contains nicotine, tar and carbonmonoxide.

The bold assurance with which arelatively small country in Latin Americahas ordered yet another set of warnings—the fourth since 2006—is a mark of justhow far this aspect of tobacco control hascome in a relatively short time, as well asof the Uruguayan government’s admir-able determination to place appropriatelabels on a uniquely dangerous product.The bloody fights waged in countries suchas Canada, a pioneer of modern graphicwarnings, seem a very long time ago.Absurd arguments and desperate threatsmay still be used by the tobacco indus-try—in Canada, for example, they gavestraight-faced assurances that more than afew colours were technically impossible,while threatening to take their packageprinting work to the USA—but now thatthe great graphic warnings race is welland truly off the starting blocks, weshould see progressively less of suchnonsense, and progressively more creativeand effective ways of showing just whatis contained in those once alluring packs.

KAZAKHSTAN: PUBLIC SMOKING BANLike Bulgaria (see page 429), just a few yearsago Kazakhstan would not have beenexpected to turn up on a list of countrieslikely to ban smoking in all public places.But as the health ministry said whenannouncing such a move in September,the central Asian country is now followingthe recommendations of the World HealthOrganization, according to whose datamore than 30,000 people die every year inKazakhstan from smoking. Sports stadiumsand public transport facilities were alreadysmoke-free, but Kazakh bars and night-clubs, and all other remaining public areasnot previously covered by the ban, havenow been forced to go smoke-free. At thesame time, the age at which people may besold alcoholic drinks has been raised fromeighteen to 21, in view of the country’ssignificant problem of alcoholism.

RUSSIA: WHAT IS JTI PLAYING AT?The acting profession and the tobaccoindustry have shared a long and infamoushistory, promoting the fiction that smok-ing is glamorous. While campaigns,including Smoke Free Movies, haveexposed the industry’s extensive use oftactics such as paid endorsement andproduct placement, the linking of smok-ing with aspirational lifestyles remains akey strategy.

This is evident in a casting call thisautumn for jobbing British actors byEyecandy Model and Promotions Agencyfor a job to help launch a new brand ofcigarette in Russia. But the call is not foran acting part in a commercial film.Regulation of tobacco advertising hasprogressively tightened in Russia since2002, with restrictions on television andradio, and a ban on outdoor tobaccoadvertising since 2007. New legislation iscurrently making its way through theRussian parliament which would makethe country compliant with FCTC stipu-lations for a comprehensive ban ontobacco advertising, promotion and spon-sorship. According to Euromonitor, theserestrictions have made it extremely diffi-cult to launch new brands in Russia,currently the third largest cigarette mar-ket in the world by volume.

Tobacco companies in Russia havetherefore shifted increasingly to indirectmarketing methods. The casting call for a‘‘good looking’’ British actor aged 25-48,with ‘‘well groomed hands’’, is a goodexample. The 8-week job takes the nowfamiliar distribution of free samples inbars even further by requiring the actor to

All articles written by David Simpsonunless otherwise attributed. Ideas anditems for News Analysis should be sentto: d.simpson@iath.org

Uruguay: the back and front of one of the newUruguayan pack health warnings, focusing onthe little known presence of toxic chemicalssuch as lead and cadmium in cigarette smoke.

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play the part of a ‘‘vitolier’’, a seeminglymade up word meaning ‘‘tobacco expert’’,which is likened to the respected positionof sommelier, a master of all aspects offine wines. For £125 ($204) per day plus£15 ($24) expenses, the actor will visitrestaurants, with an interpreter, to playout the following scenario on unsuspect-ing members of the public.

A script outline dictates the essentialshape of each visit, starting with the‘‘vitolier’’ and interpreter entering a res-taurant and taking a seat at the bar,looking for a table with smokers, sendingover a waiter with a note in which ‘‘aBritish tobacco expert from London’’ asksto talk to them. After introducing himself,the actor says he has been invited byJapan Tobacco International (JTI) to visittheir country and that he is ‘‘reallyinterested in the tastes of Russian smo-kers.’’ He is then to converse with themabout their tastes and preferences regardingpremium cigarettes, also telling them about‘‘the English tobacco traditions’’, mention-ing Sobranie cigarettes and recommendingthe new Sobranie product. Finally, ‘‘Hetells them about the tones of premiumtastes… the latest trends in contemporaryart, and recommends the current art-project of Sobranie in Moscow.’’

Sobranie of London, established in1879, is one of the oldest tobacco brandsin the world. Originally handmade andsupplied to royal courts across Europe,today Sobranie brands (including BlackRussian) are produced by JTI and areamong the most expensive in Russia. Thecompany’s aim is to encourage smokers to‘‘trade up’’, from lower priced cigarettes tohigher priced brands. To promote its high-end image, Sobranie also sponsors theMillionaire Fair Moscow, ‘‘a leading exhibi-tion of luxury, despite and contrary to theworld financial crisis’’. The casting of aBritish actor to play the part of a ‘‘vitolier’’,dressed in a suit and armed with a ‘‘frank,straightforward, honest, and pleasantsmile’’, is part of that strategy.

What is perhaps most remarkable ishow out of touch the whole campaign iswith the economic and social realities oflife for most Russians today. Amid globalrecession, the Russian economy has beenhard hit by the decline in world commod-ity prices. Unemployment reached 8.5 percent in October and the official inflationrate for 2009 is running at 13 per cent.These recent problems have worsenedlonger term declines in living standardssince the mid 1990s. Male life expectancyhas plummeted to less than 59 years in2008 (compared to 72 years for females),well below the 74 years of men in western

European countries such as France andGermany. While staggering levels of alco-hol consumption have a lot to answer for,smoking is also taking a major toll. Withmale smoking rates at 61 per cent, thenumber of reported cases of lung cancerhas increased by 63 per cent over the lastten years. Smoking is cited as the maincause for 52 per cent of all cancer cases,the biggest cause of premature deathsalongside heart disease.

With most Russians struggling to earn adecent living, JTI’s attempt to launch anew luxury brand of cigarette really doesbelong in the realm of fantasy. The wholecampaign has an air of fiddling whileRome burns. One must also ask whethertobacco advertising executives really arethat out of touch with reality. Or is thisjust another example of the creativity ofthe industry in seeking to circumventstronger regulation? JTI claims that it‘‘believes that appropriate regulation oftobacco is both necessary and right, in theinterest of public health. We believe thatthe WHO, sovereign governments, non-government organizations and thetobacco industry should all work togetherto resolve these issues.’’ If the companyreally believes this, perhaps it should thusstop play-acting and tell the truth.

KELLEY LEELondon School of Hygiene & Tropical Medicine, UK

kelley.lee@lshtm.ac.uk

UK: SMOKER’S LUNGS KILL TRANSPLANTMANA coroner’s court examining a Britishsoldier’s death from lung cancer in 2008heard recently that the 31-year-old manhad received a bilateral lung transplantthe previous year after being diagnosedwith an incurable lung condition.Immunosuppressive drugs prescribed tohelp his body accept the new lungs, whichhad an undetected tumour, simplyincreased the speed of its growth. Oninvestigation, it was revealed that he hadreceived the lungs of a smoker of 30 to 50hand-rolled cigarettes per day.

While most people know that onaverage, smokers die younger, often fromserious diseases caused by their smoking,it came as a shock to realise how many oftheir bodies were being recycled fortransplantation. In 2007, 22 per cent ofBritish adults aged 16 and over smokedand a further 27 per cent were ex-smokers; so it is not surprising that 51per cent of all organs for transplantsoriginate from smokers. The transplant-ing hospital said that the soldier’s casewas extremely rare, in an area of great

need, with half as many patients asreceive a lung transplant dying while stillon the waiting list for one; and if thehospital did not use the lungs of smokers,the number of lung transplants would besignificantly lower.

CHINA: EXPO REJECTS TOBACCO FUNDSOrganisers of the 2010 Shanghai WorldExpo recently responded to concern andrejected a 200 million yuan (US$29 million)donation from the Shanghai tobacco com-pany in order to observe the promise ofa ‘‘healthy and smoke-free Expo’’. Theannouncement came in response to severalweeks of heated debate around China inJuly on the legitimacy of allowing tobaccopromotion and sponsorship in a publicevent like the World Expo.

The debate was partly triggered by anearlier suggestion from a group of Chinesehealth experts that Expo organisersshould reject the donation, which wouldhave been a ‘‘public showcase of tobaccoadvertising’’ and a ‘‘violation of interna-tional treaties’’. They cited Article 13 ofthe World Health Organization’sFramework Convention on TobaccoControl (FCTC), under which parties areobliged to undertake a comprehensive banon tobacco advertising, promotion andsponsorship, at both domestic and inter-national levels. China, the world’s largesttobacco producer and consumer, signedthe FCTC in 2003 and committed toending all types of tobacco advertisingand promotion by 2011, and to makingworkplaces totally smoke-free.

Shanghai Tobacco, which producesChina’s major cigarette brands includingPanda and Chung Hua, donated 200million yuan in May to help build theChina Pavilion, which is expected to cost1.5 billion yuan.

The decision by the World Expo autho-rities to refuse tobacco funding was praisedby the World Health Organization.However, health experts say that an even

China: Shanghai Expo organisers initiallyaccepted a 200 million yuan (US$29m) chequefrom Shanghai Tobacco, which they laterrejected.

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bigger challenge is now before the ShanghaiMunicipal Government, as it considershow far to go in protecting the city’spopulation of 17 million people by requir-ing workplaces and public places to besmoke-free from 2010.

THAILAND: WIPING OUT THE LAST ADSThailand enacted laws prohibiting allforms of advertising from April 1992 andbanning misleading descriptors fromMarch 2006. The law mandating pictorialhealth warnings, occupying 50 per cent ofboth principal cigarette pack surfaces,became effective from March 2005.However, despite these stringent regula-tions, transnational tobacco companiessneakily placed promotional gimmickson the remaining 50 per cent of packsurfaces on their imported cigarettes, notonly promoting the cigarettes, but alsoeffectively ruining the visual impact of thehealth warnings.

In March 2009, it was found thatpackages of Philip Morris (PM) brandL&M Select bore such promotional itemsin the form of colour pictures of tobaccoleaves and a peeling filter, with the texts,‘‘A premium smooth taste with lastingflavour. Blended to perfection.’’ and ‘‘Apremium cool sensation with lastingflavor. Chilled to perfection.’’

As these were considered violations ofthe Thai laws, PM Thailand Ltd was

notified by the tobacco control section ofthe government’s Department of DiseaseControl (DDC) and asked to remove allthe offending packages from sales outlets.The company asked for and was grantedpermission to obliterate the illegal pic-tures and wordings by placing a whitepaper cover over them.

Not long afterwards, British AmericanTobacco asked DDC to consider a modelprepared by the company for its Pall Mallcigarette packs. The design contained aphrase promoting the product, with a logostating, ‘‘Sun Ripened Tobacco’’ and theaccompanying phrases, ‘‘Naurally SunRipened Tobacco’’ and, ‘‘More Taste.’’The company also enclosed a photocopyof a document from the Department ofIntellectual Property accepting BAT’srequest to register this as a trademark.

In a decisive blow for health, theproposal was turned down by DDC—shutting the door on a promotion thatcovered part of the health warning on thecigarette package.

SUNIDA PREECHAWONGChulalongkorn University, Thailand

sunida.p@chula.ac.th

BULGARIA: TAX RISE TO CURB SMOKINGHaving previously had little or no effectivetobacco control policies, Bulgaria spranginto action recently when its financeminister not only announced a 43 per centrise in tobacco excise tax to be applied fromnext year, but stated plainly why the newgovernment, elected in July, was taking themeasure. While it will raise much neededrevenue, the minister emphasised that itwas primarily a health measure.

Bulgaria is the second heaviest smokingcountry in Europe, after Greece, partlyinfluenced by its former position as themost important tobacco supplier withinthe former socialist bloc of central andeastern European states. More than halfof men and more than a third of womenare smokers, with the population suffer-ing correspondingly high rates of tobaccoinduced disease. The government is alsoto ban smoking in all public spaces fromJune next year. For those whose experi-ence of Bulgarian public places is of someof the smokiest in the world, the imple-mentation of this major change will be ofparticular interest.

INDIA: COUNTERING THE IMPACT OF PACKWARNINGSA new type of product, already familiar inother countries, was launched onto theIndian market recently and is now readily

available at easily accessible tobacco out-lets at all the markets which young peoplefrequent. The product is called a ‘‘smoke-shirt’’, a name that might suggest that itis made of cloth; however, it is anattractive, sophisticated cover for a cigar-ette packet. Creatively designed pamph-lets promoting smokeshirts are beingdistributed in up-market areas, apparentlytargeting Indian young women and girls.They give detailed information aboutsmokeshirts, positioning them as a stylish

Thailand: companies using promotional devicespartly covering the health warnings on cigarettepacks to get round Thai advertising and healthwarning regulations have been ordered to stopusing them.

India: a leaflet promoting the Smokeshirtcigarette pack holder.

India: a Smokeshirt pack holder.

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accessory with designs to suit everyone’staste. They are available in a variety oftop grade textiles, the leaflets say, fromstripes and polka dots to leopard skinprint, to match one’s clothes and suitablefor any occasion.

Currently smokeshirts are beingimported from Germany. Made by acompany called Lifestyle and Fashion,they were invented by two brothers,Joerg and Michael Knobloch. Their aimwas to enable smokers to cover up thegraphic health warnings on cigarettepackets that are now being adopted inmany countries. The Knobloch brothers,who describe the smokeshirt as a ‘‘life-style product’’, reportedly conductedextensive research of patent officesaround the world to ensure that theywere launching a unique product, as wellas selecting product features and pricingbased on market research in Germany.They also researched pack sizes of cigar-ettes around the world to determine thedimensions of their product. A designteam then produced a range of smokeshirtdesigns.

India delayed the implementation ofpictorial warnings time and again from2006, due to pressure from the tobaccoindustry, but they were finally enforcedon 31 May 2009. The launch of smoke-shirts in India, just a few months beforethe pictorial health warnings were imple-mented, is clearly a way of countering theimpact of the new warnings. Along withthe implementation of pictorial warnings,India’s new regulations prohibit the saleof any product which can be used to coveror obscure the warnings. Thus, with thenew regulations coming into force, thesale of smokeshirts has become illegal inIndia, but they continue to be on themarket. Smokeshirts also have a comple-mentary neckband, whose use makes thesmokeshirts easily accessible and visible,making it unnecessary to keep them in apurse or pocket.

Apart from India, smokeshirts areavailable in European clothing and designshops from Portugal to Hungary and inmany locations in China. A statementfrom the Knobloch brothers about theirproduct reads, ‘‘Our retail partners aren’ttaking any risks because our productspractically sell themselves in no time atall, and they offer excellent value formoney. We receive follow-up orders allthe time, and we are able to fill them

immediately, because it’s always ourpolicy to overproduce during the firstmanufacturing run. We see this as animportant service we offer our retailpartners.’’

As increasing numbers of countries addthe requirement for pictorial health warn-ings to their tobacco control laws, theywill need to address the likely emergenceof smokeshirts to counter the effect of thewarnings. They will not only need tolegislate specifically against productsintended to cover up the warnings, but,unlike India, show that they mean busi-ness by acting quickly and decisively toenforce this and all other tobacco controlregulations.

PRIYANKA DAHIYA & MONIKA ARORAHRIDAY (Health Related Information Dissemination

Amongst Youth), Indiamonika@hriday-shan.org

MICHAEL RUSSELLThe distinguished research scientistMichael Russell, whose work was soimportant to understanding why peoplesmoke and how they can be assisted tostop, has died aged 77. Born in Capetown,South Africa, he studied medicine in theUnited Kingdom, at Oxford and Guy’sHospital, London, returning to SouthAfrica and working as a junior doctor atGroote Schuur Hospital. After deciding tospecialise in psychiatry, he and his wife,Audrey, both deeply unhappy with apart-heid, returned to London to train at theMaudsley hospital. Working in Griffith

Edward’s Addiction Research Unit at theInstitute of Psychiatry, he chose smokingas his research thesis topic and in 1971published a seminal paper concluding thatnicotine was the motive force behindsmoking.

Recognising the need to measure smokeintake accurately, Russell recruited bio-chemist Colin Feyerabend to develop amethod for measuring blood nicotine. By1974 he could quantify intake withprecision and even measure non-smokers’exposure from passive smoking, one ofmany ‘‘firsts’’ in the field. As his under-standing grew of smokers’ self-titration tomaintain nicotine levels, he was also oneof the first (at least outside the tobaccoindustry) to understand how lower emis-sion cigarettes were flawed.

It was Mike Russell who persuaded apharmaceutical company to produce theworld’s first nicotine chewing gum,designing a randomised trial to test itsefficacy at the Maudsley clinic, as well aslater co-developing nicotine nasal spray.His work thus laid the foundations of thenicotine replacement industry.

In addition to the full spectrum oftobacco pharmacology, Russell’s researchalso covered wider aspects of appliedcessation. He showed, for example, howthe mere completion of a questionnaireabout smoking by patients waiting to seea family doctor led to a measurable long-term reduction in their consumption,with brief advice from the doctor yieldingaround five per cent one year abstinence.He was a familiar figure at tobaccocontrol meetings, where his sometimesfiery defence of his views contrasted withkind and caring support to successivedirectors of Action on Smoking andHealth and other tobacco control work-ers. Russell was appointed Professor ofAddiction in 1986.

He was the recipient of the AltonOchsner Award, an international prizefor outstanding research on tobacco andhealth, in 1996, and the Ferno Award ofthe Society for Research on Nicotine andTobacco in 1998. Having returned toindependent South Africa, MichaelRussell’s last few years of retirement inCapetown were marred by Alzheimer’sdisease. He is survived by Audrey and hissons James and Nicholas.

Tobacco Control 2009;18:427–430.doi:10.1136/tc.2009.034454

Professor Michael AH Russell, 9 March 1932 to16 July 2009.

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