News analysis Tob Control: first published as 10.1136/tobaccocontrol-2015-052740 on 22 October 2015. Downloaded from Worldwide news and comment

USA: ALTRIA, CYCLING’SLATEST DRUG STAIN Altria is boasting on its website that it is a founding partner of the Richmond Union Cycliste Internationale (UCI) Road World Championships, held in September 2015. The sponsorship is highlighted in an upbeat video that makes no mention at all of the company’s main line of business. Pascal Fernandez, senior vice president, Consumer and Marketplace Insights at Altria Client Services talks about growing up in France watching Tour de France “I did bike racing myself and I’m…super excited to think we’re going to be hosting this event, we’re going to have all these champions coming into town, showing a different side of Richmond…” Exactly what is meant by showing a dif- ferent side of Richmond is not clear – perhaps Mr Fernandez means the contrast of an elite international sporting event hosted by a town which is home to a fi

multinational company where pro ts can copyright. be counted in the number of lives cut short. Certainly the vision of cyclists at the peak of aerobic fitness is a striking contrast to the misery of the last years of many smokers, tethered to an oxygen machine or disfigured by cancer surgery.

EUROPE: TRANSPARENCY BLACKED http://tobaccocontrol.bmj.com/ Absurd juxtaposition: this image of an elite cycling event sponsored by Altria is strikingly at odds OUT ON with the reality of lives ruined by smoking, as shown by the lower image taken from a UK The European Commission has been criti- anti-smoking ad which tells a heartbreakingly common story of a man with lung and throat cised by NGOs and Members of the cancer 10 days before his death. European Parliament (MEPs) for failing to adhere to its transparency obligations as a ’ party to the World Health Organization Day s team and the tobacco industry, and Union law, and denied that the documents fi Framework Convention on Tobacco was led to determine if EU trade negotia- had anything to do with the TTIP. Control (FCTC). The criticisms arise from tors were pushing for investor to state However, secretary general Day a Freedom of Information (FOI) request dispute settlement (ISDS) provisions in defended the redactions on the basis that “ lodged by NGO Corporate Europe trade agreements. ISDS provisions have the public interest in transparency does Observatory (CEO) in March 2015 for been used by the tobacco industry to neither outweigh the public interest in on September 23, 2021 by guest. Protected ’ documents related to the Transatlantic mount legal challenges to national protecting the Commission s international ” Trade and Investment Partnership (TTIP), tobacco control provisions in countries relations and decision-making processes a proposed free trade agreement between such as Uruguay and Australia. and stated that because the documents the USA and the European Union, Following a series of delays, the last of contain elements related to the fi ’ expected to be the largest trade agreement the documents were nally released in Commission s negotiating position with in history. August, but were so heavily redacted as to regards to tobacco in bilateral negotia- The FOI request was about meetings be virtually meaningless. Names of tions for a free trade agreement with the between EC Secretary General Catherine Commission staff, content, dates and even USA and Japan, they cannot be released page numbers were blacked out. The as they would reveal the Commission’s European Commission’s justification for negotiating positions and tactical the redactions has been contradictory: considerations. All articles written by Marita Hefler Commission deputy chief spokesperson Ms Day’s statements appear to suggest unless otherwise attributed. Ideas and Alexander Winterstein stated the redac- that the tobacco industry has had privi- items for News Analysis should be sent tions were to guard commercially sensitive leged access to information, a concern to: marita.hefl[email protected] information and adhere to European raised by Irish MEP Nessa Childers, who

Tob Control November 2015 Vol 24 No 6 523 News analysis Tob Control: first published as 10.1136/tobaccocontrol-2015-052740 on 22 October 2015. Downloaded from

A screenshot from the powerful Voice of Tobacco Victims campaign.

has now been banned in the majority of the country, with encouraging results. Spurred by attractive packaging in single-dose plastic packs affordably priced at 2–3 cents/pack, and widespread market- ing targeted at children and adolescents, the gutka market has rapidly expanded in the last decade to be worth more than US $8 billion. The growth of the industry has caused havoc with public health, espe- cially oral health. According to the Global Adult Tobacco Survey (GATS) 2009–10, around 13% of males and 3% of females used gutka in India. Among young people aged 15–24, use was 23% for males, and 8% for females. Use of smokeless tobacco usage is a key risk factor for cancer (mainly oral, oesophageal, and pancre- atic), stroke, ischaemic heart disease, type 2 diabetes, adverse reproductive and copyright. developmental effects such as stillbirth, preterm birth and low birth weight. The legal basis for the gutka ban was the Food Standards and Safety Act notified in 2011, section 2.3.4 of which specified that “Product not to contain any substance that may be injurious to health: tobacco

and nicotine shall not be used as ingredi- http://tobaccocontrol.bmj.com/ ents in any food product”. At the direction of the Supreme Court, the Ministry of Health and Family Welfare (MoHFW) constituted a high level Expert Committee to collate the evidence on harmful effects of smokeless tobacco and . In A 14-page redacted letter from the tobacco industry as redacted by the European Commission in February 2011 the Ministry submitted response to an FOI request by Corporate Europe Observatory. Source: http://corporateeurope.org/ this report, commonly called National international-trade/2015/08/black-out--access-eu-trade-talks-eerie-indication-ttip-threat Institute of Health and Family Welfare (NIHFW) Report to the Supreme Court. has called on Ms Day to clear up any con- with the tobacco industry. She called for Several Civil Society NGOs urged the on September 23, 2021 by guest. Protected fusion and asked the Commission to all meetings and their minutes to be pro- highest court to ban the manufacture and confirm that the documents had nothing actively published online. sale of all products found to be injurious to do with the TTIP. to health by the NIHFW health report. Despite years of controversy over INDIA: SMOKELESS TOBACCO BAN Momentum for the gutka ban, however, tobacco industry lobbying leading up to SHOWS EARLY SUCCESS came from tobacco victims themselves; the adoption of the European Union’s ‘Bans don’t work’ is a common response survivors of cancers of mouth and throat, revised Tobacco Products Directive, the to measures to restrict or outlaw tobacco widows and families of tobacco victims. Commission’s latest actions suggest that it supply. Libertarians decry such measures as Known as ‘Voice of Tobacco Victims’ continues to treat the tobacco industry in excessive ‘nanny state’ intervention; others (VoTV), the campaign featured patients the same way as any other business. point to the USA experience of alcohol and their family members, supported by CEO filed a complaint with European prohibition in the 1930s, often held up as their treating oncologists and public health Ombudsman Emily O’Reilly, who found a failed experiment. However, India is researchers, telling their stories of initi- that – with the exception of the DG proving that prohibition can have a place ation and addiction to gutka and conse- Health – the Commission was not suffi- in public health. Gutka, an industrially quences of disease, financial ruin and ciently transparent about its meetings manufactured smokeless tobacco product agony.

524 Tob Control November 2015 Vol 24 No 6 News analysis Tob Control: first published as 10.1136/tobaccocontrol-2015-052740 on 22 October 2015. Downloaded from

Started in 2011, the target audience for affected the purpose and consequent of a banned product led to erosion of the the VoTV was top policy makers, bureau- impact of the ban and was possible due to brand values. The ban has effectively dis- crats, social influencers, media and politi- weak enforcement of the law. However, rupted supply, especially reducing access cians. The appeal from patients made 11 states took action by banning the sale to children. direct emotional connections; politicians of processed and packaged smokeless This is an edited version of a story ori- and bureaucrats made promises and media tobacco and flavored areca nut products. ginally published on the Tobacco Control gave prominent coverage to stories. The A concern for public health policy website. The full article, including links to VoTV doctors and staff provided scientific makers and researchers was to determine references and additional author credits, evidence, made the advocacy demands if gutka chewers switched to smoking fol- can be accessed at http://blogs.bmj.com/tc/ very specific, and followed up with lowing the ban. Studies have consistently 2015/08/27/can-prohibition-work-the-case- bureaucrats and politicians until the shown that there is almost no switch over of--smokeless-tobacco-ban/ fi objective was met. Ultimately, the rst to smoking. In fact, the whole campaign Pankaj Chaturvedi gutka ban was declared by the state of for the gutka ban, aided by other tobacco Tata Memorial Hospital, , India on 1st April 2012. control measures, seems to have impacted [email protected] Thereafter, state after state notified the sales of all forms of tobacco. According to ban. For some states who refused to imple- the Index of Industrial Production (IIP) Sanjay Seth ment bans, public interest litigations were data, output of tobacco declined by Healis Sekhsaria Institute for Public Health filed and High Court judgments forced 12.1% in March 2015 from a year ago. them to declare the gutka ban. By the end The Euromonitor report on Smokeless INDIA: BECOMES FIRST 2012, 14 of India’s 29 states had notified Tobacco in India, published in December TOBACCO AD-FREE STATE the ban and in April 2013, the Supreme 2014, revealed that up to 2010, volume Kerala has become the first state in India Court directed all states to comply. of sales as well as the value of sales of to become tobacco advertisement free. The extent of enforcement of the ban smokeless tobacco were increasing, were This major milestone for public health in varies a great deal across states, but there more or less stagnant in 2011, and by the country represents strong government have been some common findings. The 2013, there was an 84% decline in commitment, a favourable policy frame- first major impact assessment report came volume and 82% decline in value of sales work, accountability, and engagement by in 2014, from a study conducted by the compared to the peak in 2010. Further, various departments to achieve robust Johns Hopkins University Bloomberg compared to 2012–13 figures enforcement. School of Public Health and the World Euromonitor predicted the decline in sale The first step was successfully abolishing Health Organization. Surveys were con- volume to be 85% and value to be 80%. tobacco advertisements at the points-of- copyright. ducted with 1,001 current and former Euromonitor attributed this decline to the sale – an effective and easy option used to gutka users and 458 tobacco product gutka ban. Also, for the first time in the create a sustained reminder about these retailers in seven states (, , history of the cigarette industry in India, dangerously addictive products. According , , Madhya Pradesh, the volume of sales have started declining. to the Global Adult Tobacco Survey and Orissa) and . These findings assume even greater 2009–10, 44.2%, 70.9% and 72.3% of Interestingly, 90% of respondents desired importance when considered along with Kerala adults above 15 had seen advertise- that the government should ban the the overall economic impact of tobacco ments on cigarettes, bidis and smokeless manufacturing, sale and distribution of use in India. According to a report by tobacco respectively. http://tobaccocontrol.bmj.com/ other forms of smokeless tobacco. MOHFW, health care losses due to treat- Kerala is home to 34 million people. According to the study, there was virtu- ment of tobacco-related illnesses were US The state’s Chief Minister, Mr Oommen ally no retail outlet where pre-packaged $16.5 billion [Rs.1.04 trillion] in 2011. Chandy has said, “Public health has been gutka was on display. Ninety two percent In comparison, in 2013–14, the and will be our priority. Over the last four of respondents supported the ban and Government’s earnings from tobacco taxes years, we have undertaken far-reaching 99% agreed that bans are good for the were US$2.83 billion [Rs.17,800 crores]. tobacco demand and supply reduction health of India’s youth. Of the respon- The findings here reaffirm the fact that measures such as a ban on pan masala and dents who continue to use illegal pre- investment in tobacco control policies gutkha containing tobacco or nicotine, an packaged gutka, half reported they represents a win-win for government, increase in tobacco product taxes, and consume less since the bans. 80% believed public health and the people and families successful completion of the drive to that the ban would motivate them to quit, of tobacco users or potential users. India’s remove advertisements at the points-of- on September 23, 2021 by guest. Protected and nearly half of attempted to do so. Of experience shows that prohibition of pro- sale in the state”. the respondents that quit since the bans, a ducts may be a credible tobacco control The Public Health wing of the Kerala substantial proportion in each state (from option in certain situations. In this case, Health Services Department spearheaded 41–88%) reported that they “quit using the product was primarily manufactured the extensive campaign that resulted in gutka because of the ban”. The study was in one country and cross border supplies removal of tobacco advertisements from a rapid survey in 7 states, rather than a could be reasonably controlled. In addi- 95.3% of points-of-sale over an 18-month nationally representative survey. tion, the ban appears to have led to denor- period across 14 districts of the state. Following the bans, however, most malisation of gutka. By declaring the Kerala Police joined forces in this gutka manufacturers started selling two product illegal, the consequential massive mega-effort. packets: one the same mixture but earned media in the country convinced Dr AS Pradeep Kumar, a medical doctor without tobacco; and a small packet con- the public (90%+ approval ratings) that with a PhD in tobacco control and then taining just tobacco, often given free. banning this product was good for the Additional Director of Health Services Users were urged to combine and mix the public‘s health. This also countered the (Public Health) who coordinated this ingredients of two packets to create their massive brand equity makers had built up effort, said a three-phase activity plan was own gutka. This innovation adversely around their gutka brands—the “stench” developed with District Medical Officers

Tob Control November 2015 Vol 24 No 6 525 News analysis Tob Control: first published as 10.1136/tobaccocontrol-2015-052740 on 22 October 2015. Downloaded from at the core. “Sensitisation programmes INDONESIA: KRETEK CIGARETTES of smoking and advertising long banned were conducted with emphasis on Section PROPOSED AS UNIQUE ‘CULTURAL in many other countries, kretek would be 5 of COTPA for district officers at the state HERITAGE’ one aspect of Indonesia’s cultural heritage capital”. (COTPA is India’s tobacco Indonesia, one of a handful of nations to that would best be abandoned. To do control law; Section 5 bans all forms of have not signed the FCTC, has been a otherwise is to risk international ridicule direct or indirect tobacco product advertis- notable laggard in tobacco control. In at a time when most nations are working ing). “District officers in turn trained and recent months, the country has started to to end the tobacco epidemic. authorised personnel attached to Primary take some small steps towards addressing Health Centres,” he added. the enormous toll of smoking with the The districts were given the freedom to introduction of pictorial health warnings WORLD: TOBACCO RECOGNISED IN customise according to their local needs. (although enforcement has been weak). SUSTAINABLE DEVELOPMENT GOALS “This, in turn, raised the level of commit- However, in an ominous sign, in ments and ownership taking. At the state September the English-language Jakarta On 25 September, the 2030 Agenda for level, we supported the districts by Globe reported that a proposal has been Sustainable Development was adopted by framing guidelines, monitoring and advis- put forward by a committee of the world leaders. Aimed at achieving sus- ing course corrections,” said Dr Kumar. Indonesian parliament to include kretek tainable development for all, the Agenda The process that started during World (clove) cigarettes as an item of cultural consists of 17 Sustainable Development No Tobacco Day 2013 saw both inte- heritage under the country’s Cultural Goals (SDGs), which mark a turning grated and intense drives that effectively Heritage Law. The proposal would elevate point for addressing non-communicable pooled the services of health personnel kretek cigarettes to the same status as disease, and recognise tobacco control as from district to primary health centre important archaeological sites and tradi- a strategy to address sustainable develop- level. Over 130,000 points-of-sale were tional arts, and oblige the government to ment and improve health. The FCTC is inspected in drives held in two phases, support the kretek industry. one of four means of implementation for from June to December 2013, and in The proposal was criticised by Vice SDG 3 (Health), and tobacco taxation is January 2014, and notices issued to erring President Jusuf Kalla and other govern- referenced in the Addis Ababa Action outlets. Notices mandated that advertise- ment officials, including the Education Agenda - a framework to catalyse invest- ment boards, stickers, or posters be Minister and Health Ministry. The House ment in the SDGs. A six year campaign removed within 7–10 days. Wherever ads of Representatives Legislation Committee was led by the Non-Communicable were not removed, they were confiscated. deputy chair defended the proposal on Disease Alliance to include NCDs as a Police assisted as needed. Regular moni- the basis that kretek needed special rules global health priority. copyright. toring continued until October 2014. to protect against them “being stolen by An evaluation study by an external other nations”. As the Education Minister agency reported an overall compliance of retorted: “…not every traditional custom 95.3%–98.5% of points-of-sale free of any must be developed and preserved”. advertisement boards and 96.7% of Given the heavy burden smoking points-of-sale free from stickers and print imposes on the Indonesian people, facili- Tob Control 2015;24:523–526. advertisements. The evaluation team, with tated by poor knowledge of the dangers doi:10.1136/tobaccocontrol-2015-052740 90 trained volunteers, observed 22,344 http://tobaccocontrol.bmj.com/ points-of-sale across the state. Kerala Voluntary Health Services, a civil society organisation with a nearly four-decade- long experience in research and field implementation in Kerala conducted the evaluation study. The team looked out for hoardings, posters, stickers, display of cost, display of tobacco products or any other promotional material at points-of-sale. In November 2014, Kerala was declared the first tobacco ad-free state in India. on September 23, 2021 by guest. Protected Sustainability of the achievement is being ensured by integrating it with ongoing inspections by the Health Department in the state. This story is also published on the Tobacco Control website and can be accessed at http://blogs.bmj.com/tc/2015/ 09/04/kerala-indias-first-tobacco-ad-free- state/ Rema Sundar A range of international NGOs campaigned for NCDs and tobacco to be included in the Tobacco Free Kerala, India Sustainable Development Goals. This graphic by unfairtobacco.org highlights the links between [email protected] tobacco and poverty.

526 Tob Control November 2015 Vol 24 No 6