India: States Ban Oral Tobacco Germany

Tobacco Control 2002;11:291–295 Tob Control: first published as 10.1136/tc.11.4.293-a on 1 December 2002. Downloaded from

Newsanalysis......

India: states ban Germany: tobacco smoking rates, including those among health professionals, with levels of oral tobacco industry makes education, traditions of intelligent so- Gutkha and paan masala, two oral further inroads cial administration, and the pragmatic products used with or without to- application of science. bacco, were banned from 1 August Germany’s resistance to effective to- While it is too simplistic to focus all bacco control is well recognised and is 2002 in Maharashtra state, where even the blame on Adolf Hitler, his hatred of contributing to the rapidly rising rates smoking put a lasting stain on what school and college students are in- of female smoking in former East Ger- was to become Germany’s most seri- creasingly becoming users. The ban many. But the German government’s ous public health issue, and the unfor- covers the manufacture, storage, dis- recent acceptance of &11.8 million tunate shadow of history hung over tribution, sale, and advertising. A 1997 (US$11.6 million) of tobacco industry the nation’s public health for many survey in the capital Mumbai (for- funding for a five year tobacco control years. For tobacco control, it was prob- merly known as Bombay) found that programme purporting to prevent ably a major factor in preventing 10–40% of school children and 70% of children and adolescents from smok- Germany from becoming a pioneer college students used the products. ing has caused further outcry. The and leader in this field of health policy. Perhaps the most interesting aspects German government claims such For example, in the years immediately of the move concern how it was made. measures are in the interest of its after the second world war, cancer First, no new law has been passed: the population. It has clearly not read the researchers who suggested that an ban was made following a state Cabi- internal documents that reveal the investigation should focus on tobacco net decision, by simply issuing an industry’s true attitude and the may have found themselves given a order under “enabling” legislation, the importance it attaches to encouraging rather wide berth. Similarly, sensible Prevention of Food Adulteration Act. rather than preventing youth smok- people, aware of the abuse of public health policy for extreme political pur- Second, it is widely rumoured that Mr ing, nor evidence which suggests that poses, would have been unlikely to Sharad Pawar, leader of the ruling at best such programmes are ineffec- tive and at worst counterproductive. It advocate that the government should political party, was diagnosed and should also perhaps re-read its con- implement action on smoking. treated for oral cancer due to gutkha tract with the industry, which explic- When Doll and Hill published their use just a few days before the Cabinet itly stipulates that “the cigarette in- retrospective study of smoking and decision. dustry, their products or cigarette lung cancer in 1950, one might have http://tobaccocontrol.bmj.com/ Many are doubtful about the poten- trading must not be discriminated expected German doctors to be among tial effectiveness of the Maharashtra against and adult smokers must not be the first to sit up and take notice. After ban, as there are few officials to denigrated”. This must clarify there- all, German scientists had been pio- enforce it and at present users and fore, for those in any doubt, that the neers in this area of research, with one illegal traders can cross into neigh- campaign was never intended to dis- producing convincing evidence of the bouring Madhya Pradesh or Gujarat courage youth smoking. link more than 50 years earlier. When states to get it. In addition, a ban on the two British scientists followed the sale of gutkha within 100 metres ANNA GILMORE with their pioneering prospective of educational institutions and gov- ELLEN NOLTE study of British doctors in the mid ernment owned offices in Mumbai has London School of Hygiene 1950s, would not their German col- and Tropical Medicine, UK not been enforced. However, the net is leagues have been the most likely to [email protected] on September 23, 2021 by guest. Protected copyright. tightening, with Madhya Pradesh and follow the fortuitous model of using Uttar Pradesh passing their own, simi- doctors as the subjects in further research, which had so boosted com- lar bans, and the Rajasthan cabinet Germany: how did it pliance in the British doctors’ study? has decided in principle to ban gutkha. get like this? But many German doctors would have In addition, the high courts in Tamil The feeling on the ground in Germany seen this whole area of research as a Nadu and Andhra Pradesh have also is eerily reminiscent of the early days poisoned chalice. The distrust of gov- ordered bans, although in each case, in the USA or the UK: the enemy ernment action on what could be seen implementation has been stayed by seems all powerful, the press appears as personal behaviour lasted well into the Supreme Court on procedural to believe nearly every word they say, our own times, and explains why pub- grounds. Oral tobacco is estimated to and the general public does not seem lic health has only become a recog- cause over 160 000 new oral cancer concerned either way. At best, people nised speciality within German medi- cases in India every year. think the health side is exaggerating, cine within the last decade. at worse that they are some sort of In addition, after the second world control freaks, unpleasantly reminis- war, the newly created West Germany cent of a part of Germany’s history was a sitting target for a huge invasion All articles written by David Simpson unless that everyone would like to forget. In from American tobacco companies, otherwise attributed. Ideas and items for tobacco control terms, Germany is not whose cigarettes became a form of News Analysis should be sent to David Simp- just the bad boy of Western Europe, currency as the country got back on its son at the address given on the inside front cover but also a country that disobeys all the feet. Today, the tobacco industry in usual rules when comparing current Germany, both local and international,

www.tobaccocontrol.com 292 News analysis Tob Control: first published as 10.1136/tc.11.4.293-a on 1 December 2002. Downloaded from represents one of the largest concen- trations of “Big Tobacco” in any Euro- pean country, with the biggest local firm aspiring to join the big boys in the international club. German politicians do not oppose action on tobacco just because of lack of education about the topic; at important times of decision, such as over the European Union directive on tobacco advertising, the industry has had up to 10 people lobbying full time. It takes two to be influenced by tobacco money, of course. Most of the political parties and individual politicians who take tobacco money see absolutely nothing wrong with it. Even the Green Party, once the brightest hope of environ- mentalists in Europe, has turned a brownish shade, impermeably tainted by tobacco funding. The news media, too, appear uncon- cerned by what goes on to keep smoking the norm in Germany. With hon- ourable exceptions, such as certain freelance journalists whose investiga- tive articles have been spiked by those who bought them, the press and broadcast media generally ignore the most important output of tobacco control advocates; and there is wide- Another cigarette advertising campaign in Unicum, this time for Polo cigarettes, featuring spread suspicion that television soap young couples embracing and inviting readers to send in their suggestions for the best places operas are tobacco funded. to flirt. The results of such long term lack of attention to the tobacco problem are http://tobaccocontrol.bmj.com/ not hard to see. The average age of aged 16 or more to smoke if they want of quirky ads centred on flirting and starting smoking among German chil- to. Revealingly, efforts to curb street other aspects of young people’s rela- dren is 13.6 years. Some schools even vending machines, a popular source of tionships. One ad shows a young cou- have smoking areas, to enable pupils cigarettes for young people, were ple in an intimate embrace, describing strongly challenged by the industry. in mock serious detail what good exer- Eventually a compromise was reached, cise kissing can be, with between 29 with the machines being upgraded— and 34 muscles involved. Readers are this is high tech Germany—with mi- invited to send in their suggestions of crochips that respond to identity cards the best places to flirt, with the lucky to restrict sales to adults. Sales are winners of a draw being sent a voucher therefore down, but it does at least entitling themselves and a partner to preserve the 800 000 machines on Sunday brunch on the sun terrace of on September 23, 2021 by guest. Protected copyright. Germany’s street corners; and it may the best restaurant in their town. not be unknown for young people to Enjoy Sunday morning, they are told; borrow their older siblings’ or friends’ and don’t forget your sunglasses. ID card to make a purchase. Magazine Needless to say, Philip Morris is in ads often refer readers to websites on the student act, too. Each year, leading to tobacco promotion pages readers of Unicum can rely on a regular where attractive prizes can be won, dose of plugs for “Marlboro Summer ideal for attracting young people, with Jobbing”—kids are told that, “In Marl- their superior web navigation skills. boro country, where freedom and The students’ magazine Unicum, adventure are at home”, everyone aged distributed free in universities and 18 and over can feel like a cowboy or colleges throughout Germany, not only cowgirl. With flights to the south west carries regular tobacco ads, but ap- of the USA and accommodation paid pears to plug other tobacco promo- by Marlboro, they can work as a ranger tions relentlessly. For example, Polo- assistant, farmhand or location scout. Advertisement appearing in the German Cigaretten-Fabrik (Polo GmbH), Ironically, travellers visiting Ger- student Unicum for “Marlboro Summer recently acquired by the UK’s Imperial many in the 1930s reported on the Jobbing”. The tobacco manufacturer covers Tobacco group, runs special promo- country’s admirable tradition of en- students’ accommodation in the USA while they work as ranger assistants, farmhands or tions for its Polo cigarette brand in couraging young people, especially location scouts. association with Unicum, using a series students, to travel, with even the

www.tobaccocontrol.com News analysis 293 Tob Control: first published as 10.1136/tc.11.4.293-a on 1 December 2002. Downloaded from smallest town providing a night’s free “an integral element of the artistic dinner, bed and breakfast for back- design” later crept in. packers at the local hostelry. Unfortu- The most useful remaining aspects nately, that aspect of history seems to of the bill are a ban on the sale of sin- have been forgotten, too, and the gle cigarettes and packs of less than intentions of the tobacco companies in 20, a ban on vending machine sales, promoting the idea, or more accu- and an enforcement of the previous rately, the image of travel to students voluntary agreement on health today are far removed from those of warnings. Some restrictions on public the small town burghers of the early smoking are set out but unfortunately, 20th century. no clear system of enforcement is specified. Russia: the lobbyist’s Industry interests have triumphed once more. Russian streets will con- art is alive and well tinue to be decorated with tobacco ads Turkmenistan recently became the and the huge death toll that tobacco first country in the former Soviet wreaks in Russia, as elsewhere in the Union to ban smoking in all public former Soviet Union, looks set to con- places. Having been advised to stop tinue. smoking following heart surgery in British American Tobacco (BAT) is continuing 2000, President Saparmurat Niyazov, ANNA GILMORE DINA BALABANOVA to promote its Sportsman brand in Kenya as Turkmenistan’s increasingly idiosyn- if smoking it were an integral part of the London School of Hygiene country’s development plan. Just as previous cratic and autocratic leader, introduced and Tropical Medicine, UK a fine—the equivalent of the mini- ads featured competitions to win a business [email protected] (see Tobacco Control 2001;10:207), a mum monthly wage—for anyone recent ad offered prizes to benefit the caught smoking in public. winners’ communities, to be presented in the Governments elsewhere in the Sri Lanka: batting winners’ names, such as agricultural fertiliser, former Soviet Union, however, seem to for health market stalls and kiosks, and even a new take a more lenient approach to smok- water supply for the village. ing, taking their tobacco control cues In the face of the tobacco industry’s from the industry rather than their incessant, high pressure promotion of smoking as a fashionable, desirable health advisors. In Russia, for exam- ence, “Let’s walk towards a healthy ple, the industry must be content at its part of life for young people, health groups keep plugging away at the real lifestyle without smoking”. Consider- recent success in ensuring that the ing the national importance of cricket,

message. One notable success was http://tobaccocontrol.bmj.com/ massive Russian market remains free originally introduced to the country of effective tobacco control legislation. achieved earlier in the year when Sanath Jayasuriya, the Sri Lankan along with cigarettes by Sri Lanka’s Despite the best efforts of a fledgling former colonial rulers, the UK, this tobacco control community, the new cricket captain, agreed to take part in a was a ball hit for six by an important federal law on limiting tobacco con- health ministry campaign against new player for the health side. sumption signed at the end of last year smoking. Under the headline ‘Don’t and being introduced in stages get yourself burnt!’, Jayasuriya tells through 2002, was reduced from an young people, the poster’s target audi- France: seminar effective bill to one simply serving the industry. In the words of a reporter on explodes under PM The St Petersburg Times, the changes It is gratifying when those outside the made to the draft between the first and immediate community of tobacco con- second readings were “a textbook trol advocacy say it like it is. When in on September 23, 2021 by guest. Protected copyright. demonstration of the lobbyist’s art”. July Philip Morris (PM) invited The ban on tobacco advertising French speaking, non-industry scien- included in the initial bill was removed tists from several European countries when the industry argued that it to a “scientific symposium” on PM’s should form a separate law. The single harm reduction programme to be held sentence the new legislation now in November in Switzerland, it cannot affords this topic simply refers the have envisaged just how badly the reader to the federal law on advertis- publicity, a major goal of its attempted ing which in turn is complex and con- rehabilitation programme, could go tradictory and will be impossible to wrong. Prominent in the French press enforce. Needless to say the previous was a call to boycott the all-expenses 1995 tobacco advertising legislation paid junkett. One of those behind the was based on the industry’s voluntary move, Professor Bertrand Dautzen- code of conduct and includes only berg, put it rather nicely: “The makers minor restrictions on content and of anti-personnel landmines at least placement of outdoor adverts and the have the decency not to invite ortho- timing of broadcast adverts. The origi- paedic surgeons to a symposium to nal draft of the new bill also banned Sri Lankan cricket captain Sanath Jayasuriya talk about the risks associated with telling young people “Let’s walk towards a smoking in movies but the familiar healthy lifestyle without smoking” in a health their products, or to get the surgeons’ escape clause to allow smoking if it is ministry campaign. thoughts on the subject.”

www.tobaccocontrol.com 294 News analysis Tob Control: first published as 10.1136/tc.11.4.293-a on 1 December 2002. Downloaded from

Twenty years ago there was little sophisticated promotion and it was largely restricted to the cities. Now, not only the use of cigarettes but their promotion, too, has become much more widespread, even reaching some of the most remote and rugged areas of this large country. The Lakson Tobacco Company, a local cigarette manufacturer, has not been slow to learn the tricks of the international invaders. Far up in the north lies Lake Saif-ul-Malok, considered one of the most beautiful lakes in the world and now a burgeoning tourist destination for Pakistan’s emerging middle class and others who can command the price of the four wheel drive vehicle necessary to reach it. But go to this otherwise almost untouched paradise, Demonstrators outside the UN building in New York, calling on the US government to take a surrounded by beautiful mountains more responsible role in the FCTC negotiations. capped with snow even in high summer, and you will find that United Nations headquarters in New tobacco promotion has got there USA: New York York City. Their message to the US del- first. The shelters provided for visitors egation to the FCTC negotiations was: to sit and inhale the tingling fresh air protest “Save Lives, Not Big Tobacco!”. The and gasp at the beautiful scenery pro- In a year when the world grew ever centrepiece of the demonstration was mote a Lakson brand called Morven, more cynical about the United States’ a large model of a Marlboro pack, sub- also the name of several beautiful role in the Framework Convention on tly improved to specify the contents as lochs and mountains in Scotland. Tobacco Control (FCTC) negotiations, “US pack of lies”. There are no hotels in this area it was heartening to see protests by US Accompanying the pack were two of Pakistan, nor electricity, yet citizens calling on their government to large, removable cigarettes bearing refreshment stalls are well stocked take a responsible, leadership role in common ‘lies’ that delegates said were with cigarettes; and one recent visitor support of a tough convention. In July, repeatedly been promoted by both the saw small children smoking their http://tobaccocontrol.bmj.com/ several hundred people, including US delegation and Philip Morris, mak- wares. around 200 teenagers involved with ers of real life Marlboro cigarettes. Meanwhile in September, doctors the Reality Check youth empower- Another two cigarettes bore straight and other health advocates at the ment programme, convened near the statements, such as “Tobacco Money is other end of the country received a Addictive”. Being New York, noted for bitter disappointment. Having been the sardonic humour of its citizens, encouraged to think that the govern- one of the cigarettes proclaimed: “Low ment, after some unusually severe Tar Death is Healthier”. prodding in recent years, was actually going to bite the bullet on tobacco control, they found when they saw the Pakistan: a hard long awaited measures that they bore and lonely struggle the unmistakeable fingerprints of the on September 23, 2021 by guest. Protected copyright. for the resistance tobacco industry. Firstly, the draft As recent editions of Tobacco Control have illustrated, Pakistan has become an adventure playground for young These children’s shorts were bought recently tobacco advertisers. The country has, in Niger. No doubt the makers of Marlboro, of course, a long history of cigarette if contacted about promoting the brand to smoking, directly attributable to the children, would throw their hands up in horror and decry the outrageous and illicit strong cigarette industry fostered by reproduction of their logo, and commission its former colonial rulers, the UK. Like teams of writ-bearing lawyers to scour so many developing countries, Paki- Niger’s street markets trying to track down stan now lives under a different form the culprits. But even if the shorts were of colonialism, with BAT and other produced entirely independently of the manufacturers, imitation is the sincerest form tobacco companies, including some of flattery. The very fact that tobacco brands local imitators, greedily exploiting its are among the most popular brands for illicit large population of male smokers, and copying in many of the poorest countries in drooling at the prospect of eventually the world illustrates just how well known, Tobacco promotion continues to reach the positive, and youth friendly are the images doubling their sales by recruiting the most remote regions of the world—this time, created for cigarettes by promotional traditionally non-smoking female the beautiful surroundings of Lake activities. population. Saif-ul-Malok in northern Pakistan.

www.tobaccocontrol.com News analysis 295 Tob Control: first published as 10.1136/tc.11.4.293-a on 1 December 2002. Downloaded from legislative proposals turned out to be restricted to the capital, Islamabad, with a straight faced explanation that health was a provincial matter, precluding the government from imposing a law on the provinces, something that may come as a sur- prise to health workers in other fields of interest. Secondly, tobacco promotion on television, radio and in the print media will continue as before, subject only to clearance from a special committee (an old trick pio- neered in Britain). Disappointment in the health community was profound. Doctors gath- ered at the Karachi Press Club and lodged a strong protest to the government about the proposed ordinance. Their press conference received exten- sive television and newspaper cover- age. While knowing that the proposed measures would be useless as drafted, At the opening session of the Third European Conference on Tobacco or Health held in they did at least have the satisfaction Warsaw in June, the First Lady of Poland, the wife of the country’s President, invested British of seeing how large a group they could epidemiologist Professor Sir Richard Peto with the Order of Merit of the Republic of Poland gather at just a few days’ notice. For (Officer Cross) for his contribution over many years to the country’s long and successful fight against diseases caused by tobacco. these are working doctors, and have to leave their busy clinics and other professional commitments to make each had to pay the equivalent ofal- that there is still little money available their protest. The press conference most US$20 from their own pockets to for tobacco control work in developing had the representatives from many fund the event, a significant sum inPa- countries. These people have the cour- academic institutions as well as vari- kistan. To fund anything like this they age and motivation to fight against the ous professional organisations such as always try to beg funds from pharma- big tobacco giants, but shortage of the national chest and cancer socie- ceutical companies, but usually draw a money always lets them down. Even http://tobaccocontrol.bmj.com/ ties. blank. They say they cannot help the cost of printing any materials It should be added that having no noticing that at international tobacco comes out of their own pockets. budget for this sort of thing, the control meetings, world experts talk Anyone with a solution can contact the doctors who organised the meeting about the “global war on tobacco”, but doctors’ network via this journal. on September 23, 2021 by guest. Protected copyright.