Pharmacy Tobacco Sales to Mentally Ill People

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News analysis Tob Control: first published as on 30 March 2007. Downloaded from

demonstrated that the mentally ill use The differing interpretation of a critical Canada: pharmacy tobacco to self-medicate negative mood ethical issue among Canadian provinces states, symptoms of schizophrenia, cogni- remains perplexing, though the invitation tobacco sales to tive deficits, depression, as well as side- of Alberta’s pharmacists to jointly seek mentally ill people effects of medication. As a result of this solutions is welcome. The only remaining The mental health community is finally vulnerability, mentally ill people face a real hope is for Alberta’s government to ban waking up to the reality of mentally ill risk of a perpetuation of tobacco’s already pharmacy tobacco sales, an initiative the people being disproportionately affected devastating impact. premier supported in pre-election sur- by the tobacco epidemic. In Canada, To add insult to injury, in some veys. However, the legislative wheels turn about one in five people are affected by Canadian provinces pharmacies still sell slowly, and in the meantime, mentally ill mental illness, and an estimated 50% of tobacco. In these, power-wall tobacco people west of Ontario, like the general them (and up to 90% of schizophrenics) marketing may be particularly proble- population, remain exposed to this most are smokers. They are also less likely to matic for the mentally ill as the pharmacy incongruous form of tobacco marketing. is the ‘‘place of health’’ most must quit than the general population. For this CHARL ELS group, too, the high cost of smoking often frequent to collect their medication. The conflicts between the dual roles of such Physicians for a Smoke-Free Canada, Alberta, means that regular meals, family respon- Canada; [email protected] sibilities, stable housing and other neces- pharmacies - counselling on cessation sities are relinquished, leading to an and selling tobacco - has resulted in inevitable exacerbation of a downward seven provinces and territories banning drift in society, with more social ills the sale of tobacco in pharmacies by law, further marginalising them. To retain with an additional ban, in Quebec, by the USA: not so pretty in smokers and recruit new ones the tobacco pharmacists’ own professional body in industry has conducted extensive response to a complaint by a member of pink the public. Pink is a favourite colour of marketers

research on factors impacting on the http://tobaccocontrol.bmj.com/ mentally ill, who may be seen as an easy In 2005, I filed a formal complaint targeting the coveted purchasing power of target - industry documents describe against every tobacco-selling pharmacist girls and young women. It is used to sell them as ‘‘anxious’’, ‘‘psychologically vul- and pharmacy in Alberta. There seemed everything from mobile telephones to golf nerable’’, ‘‘angry’’, and ‘‘least likely to no reason why the Quebec ruling (and clubs and pop music. Tobacco companies quit,’’ to name only a few. the ethical stance in the seven other have also cashed in on this stereotypical colour with products such as Pink There are virtually no cessation pro- provinces and territories) should not also grammes designed to accommodate the apply to the remaining provinces with Dreams cigarettes. ‘‘The name alone has special needs of severely mentally ill pharmacy tobacco sales, including head-spinning implications. Thoughts whiplash from bubblegum-n-Barbie to smokers and the barriers to their quitting Alberta. There was a general sentiment provocative porn, depending on your are perceived by many as insurmounta- among pharmacists to help protect the age, gender, and mindset,’’ notes the ble. Despite a body of evidence that public and not to support tobacco sales; and two large-scale surveys demonstrated American non-profit organization,

cessation treatment is effective, the on September 30, 2021 by guest. Protected copyright. Shaping Youth, which aims to counter majority of mentally ill people do not overwhelming support for a ban in negative marketing and media aimed at access effective, individualised treatment. Alberta’s pharmacies. However, the com- children. Isolated, positive reform has occurred, plaint was rejected. It was followed by a with mental health groups deciding to second, similar complaint naming five Not only is the outer packaging of the refuse tobacco industry funding and a specific pharmacies selling tobacco. Pink Dreams pack coloured pink, but the widespread trend towards smoke-free It took more than a year before a cigarette itself is wrapped in pink paper hospitals and healthcare facilities. response was received. A legal opinion and topped with a gold filter. Described as a super-premium product, this ‘‘fashion- However, in some Canadian provinces had been sought by the regulatory body able cigarette’’ comes ‘‘beautifully gift- "power walls" of cigarette packs in retail and the listed pharmacists had a chance boxed in a pink foil package’’ and ‘‘offers outlets remain a powerful marketing tool to provide rebuttals. These included: pure pink smoking enjoyment to today’s (see Canada: point of sale win – again. ‘‘tobacco sales are legal in Alberta’’, sophisticated female adult smokers.’’ The Tobacco Control 2005;14:78-79). Their ‘‘tobacco purchases are a matter of choice cigarettes are imported into the United impact on the mentally ill may well be which the pharmacist should respect’’, States by Kretek International (KI). KI amplified, due to cognitive deficits, ‘‘decisions are made on corporate level, distributes more than 500 brands of impaired decision-making capabilities, and not by the individual pharmacist’’ tobacco products from around the world diminished motivational and volitional and ‘‘pharmacists do not profit from throughout the USA and Canada. The assets, as well as other challenges inherent tobacco, and have no vested interest in company has positioned itself as leader in to mental illness. It has been widely the product’’. However, the spirit of the overall response was not uniform: one the specialty cigarette market. pharmacist removed tobacco from his The popular US-based website pharmacy. The complainant was notified www.punkrockdomestics.com, a discus- All articles written by David Simpson that the issue was closed (no disciplinary sion board for girls and young women unless otherwise attributed. Ideas and action followed) and that it was wrong to seeking counter-culture household tips, items for News Analysis should be sent use the disciplinary route as an indirect features a forum about cigarettes. to: [email protected] means to achieve a specific public policy Website members had this to say about goal. Pink Dreams cigarettes:

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‘‘i heard about these cool ciggs called motivations involved, this is another PINK DREAMS has anyone example of a tobacco company appro- tried…they come in a pink tin, and priating feminine imagery to sell its Tob Control: first published as on 30 March 2007. Downloaded from rolled with pink paper and have a deadly products to young women. gold colored filter...its [sic] the packa- BECKY FREEMAN ging that kills me!’’ University of Sydney, Australia; ‘‘My favorite color is pink. I might [email protected] have to go check out the smoke shop next week’’ ‘‘My friend got a pack of those and let Belgium: taking a lead me bum one or two.. I was just excited to be smoking a pink cigarette!’’ in Europe For many years, the corridors of power in Brussels, the Belgian capital, seemed to It is not possible to determine whether be peopled almost exclusively by tobacco these comments were posted by real lobbyists. It was not the Belgian parlia- women talking about real experiences, ment that they stalked, but the European or by women who were compensated by the cigarette manufacturer to post posi- Commission, secretariat of the European tive messages on this female-targeted Union (EU). Their mission was to try to website. Promoters of the Pink Dreams prevent the development of EU directives brand could have easily employed young that would in due course require each member state to enact effective tobacco women to join female-targeted websites Belgium: one of the new graphic health warnings to introduce the brand to other potential control legislation in its own parliament. in the first European Union member state to customers—‘‘cigarette girls’’ are already Sometimes the industry lobbyists’ stalk- implement them. an established practice in bars and night- ing would turn into a downright stam- pede, on occasions, the overwhelming clubs. Or perhaps someone with a com- of Ostend was the centre of a national majority of people packing out committee mercial interest in selling the cigarettes media frenzy when its plan to force pupils rooms would turn out to be doing the simply invented them. caught smoking to wear a badge was industry’s dirty work. Now that the EU The colour pink is also the iconic badge publicised. The badge, whose message has been expanded to 27 countries, it is http://tobaccocontrol.bmj.com/ of global breast cancer awareness cam- was along the lines of, ‘‘This is what my easy to see why so much effort was paigns, with their distinctive pink ribbons lungs look like now, for all I care,’’ also poured into the resistance movement, and associated fundraising products. pictured a full colour, graphic image of a and conversely, how much is owed to Given the obvious similarities between smoker’s lungs in an apparently advanced politicians and officials who fought it all Pink Dreams packaging and pink ribbon state of disease. However, following pro- the way on behalf of health. products, it is possible that the manufac- tests around the country, the scheme was Around the world, from Canada to turers are capitalising on the emotional dropped. There were, of course, sound Australasia, Brazil to Thailand, pioneering connection many women feel to this arguments against an approach that health ministries have researched, cause related marketing. Or perhaps it pointed the finger of blame and shame designed, tested and introduced various intends to capitalise on the popularity entirely at the unlucky young smokers, series of graphic warnings. These have of the Grammy award-winning US but the new health warnings have the singer/songwriter Pink, real name Alecia been busy playing their part, millions of

potential to do the same education job on on September 30, 2021 by guest. Protected copyright. times a day, in eroding the lingering air of Moore, who has sold more than 25 all smokers, children and adults alike, luxury and bravado that manufacturers million albums since coming to promi- smoking openly or in secret. The chal- still try so desperately to convey to their nence in 2000. Regardless of the precise lenge is to keep researching images that cigarettes via pack design and whatever will maximise the effect. other promotional tricks they can get away with. Belgium never used to be high on any European Union: list of tobacco control success or determi- nation by its government, but today it has parliament hosts BAT earned a refreshingly different connota- tion in public health circles - top of the stunt league in Europe, in fact. Last December, Just how badly does a company have to it made cigarette manufacturers print behave to be denied special access to graphic health warnings on tobacco politicians elected to safeguard their packaging, the first EU member state to voters’ health and other interests? do so. The United Kingdom is to follow Despite a long record of doing its utmost suit later this year and Romania in 2008. to prevent effective tobacco control poli- However, considering the scale of the cies in Europe, British American Tobacco battle that was fought to add such an (BAT) has been allowed to hold a lobby- important element to European tobacco ing event on its "corporate social respon- control policy, whose final clearance was sibility" (CSR) programme in the issued more than three years ago, it is European Parliament. Using the tired extraordinary how slow other EU states old rhetoric that politicians and parlia- have been to do the same. mentary officials should have learned to Perhaps the government’s zeal is catch- decode long ago, BAT billed the event, USA: Pink Dreams ing: recently a school in the busy port city held in January, as a "stakeholder dialo- www.tobaccocontrol.com News analysis 77 gue" and part of its 2006 social reporting sophistry, as well as bogus "experts" flown process. in from around the world, cut little ice

To try to make politicians and others with legislators; and the blustering, Tob Control: first published as on 30 March 2007. Downloaded from think that everyone, like it or not, is a threatening tone of testimony offered to "stakeholder" in its wretched business, is the fledgling legislative council almost one of its most invidious tricks. certainly did the industry more harm Politicians worth their salt, not to men- than good. tion salaries, can surely see through such To public health workers in Hong corporate sophistry? Moreover, they can- Kong, therefore, it was all the more not have failed to hear about the widely amusing to see the tobacco industry make publicised evidence from BAT’s own another big mistake there recently. The documents revealing the true nature of occasion was the trade exhibition Tobacco its CSR and youth education pro- Asia Expo, held in January at the gleam- USA: children at work on educational film grammes. Nor does it take much thought ing new AsiaWorld-Expo centre at Hong storyboards as part of Wyoming’s "Through with to work out how the company justifies Kong’s international airport. Following Chew" week. spending its shareholders’ money on such the participation of a health representa- public relations nonsense. Obviously, it tive in a similar show some years ago, children who apparently might usually sit must be aimed at mitigating what the such get-togethers are now billed as at home at the weekend, some with a politicians might otherwise do to reduce strictly tobacco industry-only, private chewing tobacco tin readily to hand, have consumption, the only proven way to shows. Perhaps this strictly enforced been recruited to an unusual programme. reduce future tobacco induced disease. secrecy contributed to the mistake. Working with AnimAction, a Los Angeles- Commendably, Cancer Research UK, by While the convention and exhibition based outfit that helps young people far Europe’s largest health charity, came centre in Hong Kong’s Wan Chai district develop artistic and creative skills through out strongly against the decision. Dr Jean might have been the obvious venue for devising and making animated films, King, its director of tobacco control, said, such a large trade fair, it was rejected on more than forty school children attended "There is a mountain of evidence that account of its strict smoke-free policy. a day long workshop in January to learn tobacco companies cannot be trusted to The organisers were aware that legislators more about oral tobacco and then devise deliver on their promises of social respon- were debating smoke-free legislation for animated films to pass on vital informa- sibility." She said her organisation was all workplaces, but either thought it tion about its dangers to their peers. gravely concerned by the way tobacco would be delayed even longer than the Reportedly, children who already knew http://tobaccocontrol.bmj.com/ companies seemed to be attempting to eventual marathon of six years, or that it that oral tobacco caused mouth cancer influence governments. This concern is would be sufficiently watered down to had little or no idea of its other dangers, echoed by tobacco control advocates allow smoking areas. But the new law, such as its association with cancer in worldwide, who fear that victories for banning smoking in all workplaces except other organs though the ingestion of health in recent years may breed a certain bars and leisure venues, came into tobacco tainted saliva. Armed with a complacency that allows the industry force just a few weeks before the start of much more thorough knowledge, they not just to live with the Framework event (see Hong Kong, China: bad atmo- set about their film work in small teams, Convention on Tobacco Control, but to sphere for public health. Tobacco Control knowing that the storylines and designs thrive under it. For BAT, being treated as 2007;16:3–4). Commenting on the fact judged most effective would be made into "normal" by the European parliament that AsiaWorld-Expo was now a totally real animated movies and aired on local must rate as a major step towards smoke-free venue, one of the organisers, television. Perhaps tomorrow’s cowboys renewed normality. Glenn John, editor of Asia Tobacco maga- will be more like the film-makers who on September 30, 2021 by guest. Protected copyright. zine, was memorably quoted as saying, make them famous than their tobacco "It’s kind of a drag." That’s just the point, spitting predecessors. Hong Kong, China: Mr John: for the health of the staff that have to work there all day, nowadays it’s industry’s loss of face no drag at all. South Korea: pack and smoke design bombshell Among the surprises of Hong Kong, long USA: kids chew over The former state-owned tobacco mono- established as a byword for free trade, has poly, now known as KT&G and fully been its tendency to be a place where the movie ideas privatised in 2002, dominates at home tobacco industry stubs its corporate toe, The official tourist website of Wyoming, with 72% of the market, and is rapidly and sometimes even comes a real cropper. set right in the middle of the USA, says it expanding abroad, especially in the From an adventure playground for young is the ’cowboy state’, and home to more Middle East and Central Asia, with an tobacco advertisers in the early 1980s - deer and antelope than people. But to oral eye on the rich pickings to be gained in the companies must have rated it the last or "spit" tobacco manufacturers, there are Russia and China. Since the drab days of place on earth to stop their energetic enough people, especially young people, state ownership, it has learned fast from entrapment of young people in the for it to be a lucrative market. Health its big, international competitors, and a nicotine web - it rapidly turned into a workers believe that part of the problem marketing extravaganza at the end of last public health model for the region. If the has been the promotion of the product as year showed just how far it has come in industry’s overall judgement was often "smokeless tobacco", with the implication slick and sophisticated design. inaccurate, some of its strategies were that it is safe. Wyoming has lagged Unusually, one of KT&G’s leading wildly off the mark. In challenging behind most other states to combat the brands, with about 7% of the market, is government tobacco control plans, for problem, which is now being addressed called Raison D’Etre, and has no Korean example, the tobacco companies’ use of more seriously. name. This fact, and the name itself, the massive public relations blitzes, tired old As part of the state health department’s French phrase, often borrowed for use rhetoric and patronising, see-though "Through with Chew" week in February, in English and meaning a reason for

www.tobaccocontrol.com 78 News analysis

obvious ways to go to aggressively pro- biggest Hindu festival, Shivaratri, celebrat- mote cigarettes and recruit new, young ing the birth of Lord Shiva, and another

smokers. It clearly works; apart from its clearly aimed at youth and girls. Tob Control: first published as on 30 March 2007. Downloaded from high brand share, Raison’s popularity This huge increase in tobacco promotion among teens speaks volumes. may be partly designed to take advantage The maximising of pack design as of the lengthy process of drafting and advertising will no doubt become more implementing the new law - local sources prevalent in all countries that fail to say government bureaucracy is notoriously implement tough, graphic health warn- slow. However, another likely explanation ings that destroy the highly misleading is the familiar tactic of the tobacco promotional potential of brands like industry under threat, namely making Raison. Public health law makers have the news media, hotels and other busi- to stop precocious advertising that con- nesses more dependent on tobacco adver- nects with rebellious teenagers seeking to tising revenue, to increase pressure for a South Korea: some of the Raison D’Etre packs on express themselves - "It is the reason why non-comprehensive tobacco promotion sale over the Christmas and New Year holiday I live." Otherwise, for many of the young ban. Health advocates have made special season. people who respond, it may one day be representations to the government appeal- the reason why they die. ing for swift action and catch-all legisla- existence, suggest it is aimed at young— tion, and they have even appealed to the very young—urban, western-leaning con- companies, but hold out little hope for sumers. Recent marketing developments Nepal: ad peak good news from either. amply confirm this. Since its launch in 2002, Raison - as it overshadows law is typically known - was already asso- drafters ciated with clever presentational ploys. Since the government ratified the World The main image on the pack was a cat in Health Organization’s Framework various colours, including blue and green, Convention on Tobacco Control (FCTC) with regular variations such as a Father last November, Nepal has seen a massive Christmas robe at the end of the year. increase in tobacco companies’ promo-

New packs would appear in time to cash http://tobaccocontrol.bmj.com/ tional activities. in on the country’s holiday seasons and be on sale for about two months. Last The big cigarette companies - Surya December, however, the seasonal market- Nepal, a subsidiary of India’s ITC and ing splash moved into a different league. British American Tobacco, and Seti Gone was Raison’s cat, to be replaced Cigarette Factory, a subsidiary of Philip with a variety of highly stylish and colour- Morris—have greatly increased their ful designs, including, by the company’s spending in all national newspapers and proud admission, Indie band, B-boy and weekly, fortnightly and monthly maga- X-sports music references, as well as zines, as well as on large billboards in graffiti. Many are not just appealing to shopping malls, department stores and in youth, but probably only understood by public places. Health advocates estimate those young enough to put their bodies the increase in spending to be at least on September 30, 2021 by guest. Protected copyright. through the contortions required in South tenfold. Korea’s most fashionable discos. In addition, the companies have been Unlike the brand’s name, the graffiti sponsoring musical nights at five-star are in Korean, and plug into a rap lexicon hotels in the capital, Kathmandu, as well probably more foreign than French or as in Biratnagar, the country’s second English to any South Korean past largest city, near the Indian border in the adolescence, riddled with teen desire for south, and in the western city of Pokhara, individuality and rejection of the uncom- one of Nepal’s most popular tourist desti- prehending world of stuffy adulthood. nations. With names such as Surya Lights Each ends with the catchphrase that Rhythm Nites and Surya Lights Bollywood translates as, "It is the reason why I live". Temptations: Freedom of Lights Musical Tobacco ads are banned on billboards Broadway, there is no doubt as to which and in news media in South Korea, with age groups are being targeted. In addition the exception of up to 60 per year in to promoting its namesake cigarette magazines with adult readerships. Thus brand, Surya Nepal has also been sponsor- pack design, which works at the time of ing events in the name of other brands, Nepal: a billboard promoting Surya Lites smoking as well as at the point of sale, including Shikhar Lights and Shikhar cigarettes, made by a BAT subsidiary. The brand together with internet promotions, are Filter Kings, including one to exploit the sponsored music nights in five-star hotels.