There's no smoke without fire

02 June 2008

Adam Gristwood speaks to the World Lung Foundation's Dr Judith Longstaff Mackay about global tobacco control.

The riders proceed under spellbinding blue skies, transfixed by the evening light energising the vast open plains. One of the rugged and alluring horsemen pulls a powerful stallion to an abrupt halt. Resting, yet not out of breath, the dark stranger stops to light a cigarette, savouring it in the gentle breeze. A stream runs down a water cut gully, crystal clear, in and out of the cornfields. A lizard skitters over the deep pool, bringing the riders to, and prompting, a gentle traverse toward the start of their next adventure.

What comes to mind now? Sex? Beauty? Athleticism? Independence? Prosperity? Freedom? For the men and women, boys and girls on whom the tobacco industry focuses its marketing strategy, they are not selling just cigarettes, they are selling a dream. There are over 1.2 billion smokers worldwide, with 800 million in the developing world, many lured into using an addictive product through manipulative advertising painting a picture that is a universe away from the many smokers who die prematurely, strapped to an oxygen tank. Once addicted, the tobacco industry has another guaranteed customer. Simple. Brilliant.

When British-born doctor Judith Mackay first set about trying to eliminate such ignorance to the real-life nightmare that millions of smokers have suffered, she was regarded as a lone voice in the wilderness. Now as Senior Policy Advisor to the World Health Organization (WHO) and instrumental in the development of the 2003 Framework Convention on Tobacco Control, Mackay is regarded as a formidable opponent to the actions of big tobacco.

The Framework Convention identified tobacco use as a global issue that governments have a moral duty to address. Yet, despite the attention that world governments are now giving to meet this commitment, Mackay warns that purely political barriers can be ineffectual as the tobacco industry pours its energy into other forms of promotion – from sponsorship of sporting events and beauty contests to free samples and stealth branding. Mackay believes that while tobacco companies conform to the letter of the law, they do not acknowledge the spirit of legislation.

"In the last three years, there has been tremendous concern about a resurgence of smoking in the movies," she explains. "This is not by accident – this is product placement, where the stars or the producers, or both, are actually paid on a contractual basis to promote smoking in the movies." Movies and television are a significant instigator of smoking in adolescents and despite Robert Igor, Chief Executive of Disney, pledging that smoking in future Disney-branded films would be 'non-existent', Mackay believes that smoking in the film industry is pervasive, and characteristic of the inventive marketing methods that big tobacco is employing to compensate for legislative restrictions.

The World Health Organization¹ has reported that if current trends continue, tobacco will eventually kill 650 million smokers alive today, or 10% of the global population. With over 800 million smokers in the developing world, and young smokers set to inflate the number of smokers globally to 1.6 billion by 2030, it is easy to see what inspired Mackay to act; however, it is difficult to see how she could go about influencing government policy towards tobacco control the world over.

"I am a medical doctor, I come from a background of working in hospitals and have seen smokers really suffer and die," says Mackay. "I think what history will do is to look back upon us now, and not say why were you so heavy handed or passing all this interference with personal freedom, etc. They will ask us – 'What took you so long?' You have a product on the market that kills half of the people who use it – putting it in one of the most unique situations of a consumer product, and yet somehow we treat pharmaceutical products in a far tougher way than we treat tobacco."

One of the most important achievements has been the success of her 2002 book, 'The Tobacco Atlas'². Full colour maps and images signify clearly the similarities and differences between countries. The book shows that tobacco is not just a health issue, but one that encompasses the economy, business, politics, trade, crime, and litigation. "The power of the atlas is that you can see at a glance where you stand as a country and where you stand in relation to your neighbours. It has certainly been extraordinarily popular," says Mackay.

"My priorities have always been with developing countries and female smokers – an important aspect for me is to try and prevent the rise of smoking amongst women in developing countries." The Tobacco Atlas exposes the behaviour of tobacco companies and predicts a future course for the tobacco epidemic – with grave concern for the targeting of women. Around 9% of women in developing countries currently smoke, but, increasingly, the tobacco industry is employing seductive but false images of vitality, emancipation and sexual allure to encourage women to buy cigarettes. Small percentile increases in uptake amongst women in populous countries such as China can, for the tobacco industry, more than compensate for loss of revenues from advertising bans, tax hikes and public smoking restrictions in the West.

In the developing world, tobacco advertising has elaborate and inventive methods, and cultural tricks. Mackay says this can be seen explicitly as you go from country to country. In Egypt, for example, where 44% men and 5% women smoke, the tobacco industry has tried to incorporate the use of Shisha – a type of water pipe – into tea breaks through direct advertising towards women and the development of flavours similar to the herbal teas traditionally consumed.

Tobacco economics
In 2002, Japan Tobacco, Phillip Morris and BAT, received combined annual revenue of $121bn – greater than the collective GDP of 27 developing countries. While it is in the interests of the tobacco industry to dispute the health implications of smoking, perhaps their most pervasive argument is that tobacco control is detrimental to economic growth. Approach in this regard varies – Phillip Morris' 2001 report suggested that the Czech Republic saved about $147m in 1997 as a result of the deaths of smokers who would not live to use healthcare or housing for the elderly. More commonly, the tobacco industry extends conventional wisdom – that a fall in tobacco sales worldwide could lead to huge negative impacts on employment, market stability and government revenue.

The strength of Mackay's argument against this – the truth regarding the economics of tobacco – has doubtless been a major factor in her emergence in the 2007 Time Magazine 100 people who shape our world. "If you look at the obstacles to tobacco control, top of that list is economic concerns – misperceived economic concerns. Virtually every government seems to believe that tobacco control will harm their farmers, will harm the economy, will put people out of work, and will give them less tax," she says. Not so.

Studies and research from countries around the world have shown that an increase in tax on tobacco products is the most effective tool for tobacco control – particularly among young people and people on low incomes. "Governments never get less revenue when they put the tax up," Mackay points out. "If you look not just at the economics of government, business and industry, but at the economics of the families concerned – there is absolutely no doubt that smoking, if you look at it globally, is a great debit to the economy, and is very detrimental to a country's wealth. That is the core argument. I don't quite know why the misconception has arisen – to what extent the tobacco industry has fuelled it. When tobacco advertising was banned in Hong Kong – 15 years ago – we were told that thousands of jobs and billions of Hong Kong dollars would be lost to the economy. But has this happened? No."

The Hong Kong Government is to follow up similar accusations that preceded the country's smoking ban, with an official study that will identify the true economic impact. Due to the visible success of the ban, Mackay is optimistic that this will be invaluable in countering the influence that the tobacco industry has on governments. "We have to show them up," she says, "to assist other countries and make them less anxious about passing laws."

Empowering governments, empowering people
Tobacco control involves delicate politico-socio-economic argument. For Mackay, prevalence of knowledge is about empowering governments and communities against the cunning of the tobacco industry. "As many nations were developing in the 80s and 90s, I think they felt very unable to stand up to Western pressures of big business," explains Mackay. "I think that again is now changing. In modern days, a way of helping countries to stand up to big tobacco is essentially through the World Health Organization's Framework Convention on Tobacco Control (FCTC).

"168 countries signed it and more than 152 have already ratified it. Now, if you ban advertising, this is not an isolated act of folly as the tobacco industry would try and have you believe – everybody is doing it," she says. The greatest success from the Framework Convention, for Mackay, is perhaps the prominence that tobacco control now receives on the political agenda. "I think that feeling of camaraderie and support, and being part of a family of nations that is established by the Framework Convention is extremely important. It also develops a whole Government position – it has kicked tobacco upstairs, into much more senior ministries.

"Much of the best legislation is not in the developed world at all, it is actually in the developing world," she points out. "If you look at countries like Singapore, they imposed an advertising ban even before Norway did. Mongolia has a better law than most Western countries."

Indeed, countries such as Thailand, Mackay believes, have "grasped the political nettle". In 1990, the Government challenged GATT (now the World Trade Organization) by attempting to ban the sale of foreign tobacco products. While it was argued that this violated 'equal treatment' principle, there was recognition internationally that Thailand had acted out of serious concern for the health of its citizens and the country was thus granted the right to ban tobacco advertising, set a high excise tax, control the distribution and sale of tobacco products, and require disclosure of all their ingredients. Now 4% tobacco tax goes towards tobacco control and health promotion, and the country has set a global benchmark with countries such as Singapore, who placed a ban on duty-free tobacco in 1994. Likewise, Hong Kong initiated groundbreaking tobacco control legislation as far back as 1987, by banning smokeless tobacco products.

Current projects
Mackay is currently working with the World Lung Foundation in a $125m global tobacco control project in low and middle income countries, funded by the New York City Mayor Michael Bloomberg.

The key aims of the project are to:
• Refine and optimise tobacco control programmes to help smokers stop and prevent children from starting;
• Support public sector efforts to pass and enforce key laws and implement effective policies, in particular, to tax cigarettes, prevent smuggling, change the image of tobacco, and prevent exposure to other people's smoke;
• Support advocates' efforts to educate communities about the harms of tobacco, enhancing tobacco control activities and helping to make the world tobacco-free;
• Develop a rigorous system to monitor the status of global tobacco use.

"This has moved tobacco control into a new arena," explains Mackay. "120 people employed, able to fund up to $0.5m grants all over the place – it is a serious and significant ballpark change, so I think the West can certainly help. But I think that it is important that they do not feel they have exclusivity about learning the right way to do it."

In ensuring that this new programme has the furthest possible reach, the Bloomberg project has set ambitious targets to develop a diverse range of missions in developing and middle income countries. "Bloomberg has chosen 15 priority countries. We are focusing on the countries with the largest number of smokers – prevalence times population. I am very keep to be working on this project, particularly in the early set up process, which is very much furthering what I have been doing, but with some cash for the first time – that is what's making the difference. WHO itself has employed 60 people under this project and another 60 outside of WHO; this is unprecedented in the whole of tobacco control history; therefore I am very committed to helping see this through and making it work well."

The development of such schemes and the importance of community-based tobacco control programmes throughout the developing world illustrates the vital importance of a multi-pronged strategy to counter the advance of big tobacco. "Tobacco control is very much like a pincer movement," considers Mackay. "You have a top-down movement by government – only governments can ban advertising, only governments can put health warnings on cigarettes, only governments can mandate in law smoke-free areas, and only governments can increase the tax. It is like the environment – they also have a very high responsibility to create one that is conducive to smokers quitting.

"Then you come round to the bottom-up approach – which is about working at grass roots level, helping people quit, and individual responsibility and how to engage people in developing countries. Just 10 years ago, I would have said that there were millions of people in the world who had no idea that smoking was harmful – I do not think that is true today. When more people begin to realise that there is a 50% mortality rate from smoking, there is a much greater acceptance of laws, tax and all kinds of measures that are taken, particularly if they are framed around protecting the health of children and workers."

What might we achieve?
The vital importance of Mackay's work is put into context when one considers the aggressive approach of the tobacco industry. British American Tobacco spokesman Dave Betteridge stated recently: "Does China have great potential in the future? Yes."

In approaching tobacco control head-on, Mackay exacts the kind of imagination and creativity to confront the tobacco industry directly – creativity strengthened by the realism and truth that is absent from the rugged adventurer on our movie screens. Remarkably, Mackay has great optimism and ambition to push much further and harder the tobacco control that could make a huge difference to social, economic and political mentality of governments, communities and individuals.

This for Mackay can only be achieved by thinking about tobacco control in a long-term way. "What we have to do is have an orderly reduction in the number of smokers by tax, by education, and by legislation," she explains. "When I was born in Britain, around 80% men smoked, now it is down to about 25% – it can be done."

Mackay believes that such statistics offer great possibility and that initiatives used to discourage smoking in countries such as Britain can be replicated and can succeed in the developing world. "The similarities of the product, the industry, and what needs to be done far outweigh any cultural differences. You might need to fine tune health education; for example, in some conservative countries you would not do a tobacco promotion with the term 'Kiss a non-smoker and taste the difference'. But the vast majority of tobacco issues need to be dealt with in remarkably the same way," she explains.

Achieving this goal requires persistence, ambition and realism. "Someone asked me the other day, what makes you happy about tobacco control?" Mackay tells me: "I said it is getting legislation through, or getting a tax increase, because I know it is all part of the ball that is rolling forward. There is good news and bad news, and I think you have to be realistic and optimistic at the same time."

1 www.who.int/tobacco/en.
2 A second edition of 'The Tobacco Atlas' was released in 2006.