News analysisAUSTRALIA: MAKING INDUSTRY CONTACTTRANSPARENTTobacco control advocates worldwide willrecognise a particular scenario from thebad old days. After trying for months tomeet the health minister to discusstobacco control policy, using every avail-able contact, perhaps marshalling a toplevel team of the great and the good fromyour country’s medical profession, even-tually, after false starts and postpone-ments, you get a meeting, to find that theminister has been called away. You havebeen palmed off with an official, and anot very senior one, for an inconclusivemeeting that advances your cause not oneiota.

Then you find that tobacco industryexecutives had waltzed into the minister’soffice weeks ago, soon after demanding ameeting, or even had a working lunchwith the minister and senior officials.They got a preview of forthcoming policy,the better to plan its circumvention; andyou later find that other such meetingshad taken place, with tobacco companiesactually helping to shape the policy intowhat they, backed by their friend thefinance minister, had agreed they couldwork with, meaning business could con-tinue as usual, with uninterrupted recruit-ment of young people to smoking.Naturally, when this happened, you felta unique sense of outrage. One of thefundamental injustices of tobacco controlpolicy had been illustrated, and in a mostdistasteful way.

Now, however, guidelines on how toimplement the Framework Conventionon Tobacco Control (FCTC) can helpmake such absurd situations history,because they have been designed byexperienced people and organisations gen-uinely concerned about health, nottobacco company profits. Article 5.3 ofthe FCTC says governments should pro-tect their health policies from commercialand other vested interests of the tobaccoindustry; and one of the guidelinesadopted by the conference of parties inNovember 2008 specifies that parties(governments), when dealing with the

tobacco industry or those working tofurther its interests, should be accounta-ble and transparent.

Among the first off the mark, as sooften, is Australia, whose Department ofHealth and Ageing has begun notifyingthe wider world about its meetings withthe industry. Its website says that on 22January this year, for example, a meetingwas held with British American TobaccoAustralasia (BATA), which fielded itshead of public affairs and director ofcorporate and regulatory affairs. Issuesdiscussed included points in BATA’sresponse to a recent government report,Tobacco Control in Australia: MakingSmoking History; how article 5.3 guide-lines will apply to the industry; and thetimeframe relating to the availability ofa government sponsored evaluation ofgraphic health warnings.

Australian colleagues are asking forfurther details of the meeting, as theywill, no doubt, in respect of subsequentmeetings. But even the existing detail is,in mathematical terms, an infiniteimprovement on past practice in all toomany countries, and a commendableexample of an important aspect of theFCTC and its guidelines being put intopractice.

JAPAN: AVOID SWINE ’FLU, HAVE A SMOKEIn Japan, especially in winter, it is notuncommon to see people going abouttheir business in shops, offices and in thestreet wearing white face masks. Japanmust be the undisputed world leader inpoliteness and the masks usually justmean that the wearers have coughs orcolds, and do not want to pass anyinfections to their fellow citizens.

Earlier this year, as the world firstbegan to hear about swine influenza,kiosks and pharmacies in Japan saw briskand rising demand for special face masksmarketed in response to the high level ofcitizen awareness of the possibly fatalresults of catching the disease. WhileJapan has made much progress in recentyears in trying to tackle another, far largerand longer established cause of prematuredeath—smoking—health advocates knowthere is still a long way to go to educatethe general public about the relative risksof smoking in the context of otherpotential causes of disease. So it was nosurprise that the irony of displaying cigar-ettes in close proximity to anti-swine-’flu

masks was apparently lost on some shop-keepers. The only surprise, said someobservers, was that the manufacturers orretailers had not pre-drilled a small hole ineach mask, to accommodate a reassuringcigarette.

WORLD: GRAPHIC WARNINGS WORK!Article 11 of the World HealthOrganization’s Framework Conventionon Tobacco Control (FCTC) sets outminimum requirements for warnings ontobacco packs and related materials.These have been known, from the earliestdays of tobacco control, almost certainlywith the encouragement of tobacco com-panies, as health warnings. In reality, ofcourse, they are disease warnings, con-cerning as they do some of the most lethaland unpleasant diseases from which ahigh proportion of tobacco users dieprematurely.

A new report on the effectiveness ofhealth warnings has been published bythe International Tobacco Control (ITC)collaboration project. The collaboration isan ongoing international longitudinalstudy currently in 19 countries aroundthe world, including both high and lowincome countries. Prepared for World NoTobacco Day on 31 May, the report isbased on cross-sectional and longitudinalstudies of text and pictorial warningsacross many ITC countries. It concludesthat graphic pictorial warnings are moreeffective than text-only warnings.Specifically, they are more noticeable anddominant than text warnings, heightenawareness about the harmfulness of smok-ing and motivate smokers to stop smoking.

The report’s findings provide compel-ling evidence of the effectiveness ofpictorial warnings and support the strongFCTC Article 11 Guidelines, adopted atthe Third Conference of the Parties in

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

Japan: cigarette packs on display with anotherfast-selling, disease-related item ofmerchandise, anti-swine ’flu masks, at aconvenience store earlier this year.

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November 2008, which call for pictorialwarnings on at least 50% of the package.In addition to the wealth of informationand illustrations in the report, interviewswith key experts involved in research onhealth warnings are available online.

The report, entitled Evidence and Re-commendations from the ITC ProjectFCTC Article 11—Tobacco Warning Labels,can be downloaded at: http://roswelltturc.org/ITCwarningreport.pdf and the audiointerviews are at: http://roswelltturc.org/ .

CANADA: BAT’S ‘‘GREENWASH’’Attempts by Imperial Tobacco Canada, thewholly owned Canadian subsidiary ofBritish American Tobacco (BAT), to adver-tise its new ‘‘environmentally friendly’’cigarette packaging were met with ridiculein May. The company was lambasted inThe Toronto Star, in an article written by thenewspaper’s environment reporter, afteradvertisements for its du Maurier cigarettesappeared in numerous publications acrossCanada. The ads, published in Toronto Lifemagazine, free entertainment weeklies andin bar bathrooms, said: ‘‘We have updatedour packaging to reduce its impact on theenvironment.’’ They stated that Imperialhad replaced foil wrapping with paper andits cardboard packaging now ‘‘meets stan-dards supporting sustainable forest man-agement.’’

But commentators in the Star were notbuying it. Gideon Forman of theCanadian Association of Physicians forthe Environment laughed when askedabout it. Later, when he stopped laughing,he said, ‘‘Is it green washing? Yes. Arethey making a product that is still toxic topeople’s health? Yes. So they are nowmaking a product with a little bit morepaper. Big deal.’’

A comprehensive definition of ‘‘green-washing’’ is provided by the SourceWatchEncyclopedia: greenwashing is ‘‘the unjus-tified appropriation of environmental

virtue by a company… to create a pro-environmental image, sell a product or apolicy, or to try and rehabilitate theirstanding with the public and decisionmakers after being embroiled in contro-versy.’’

Imperial’s attempt at greenwashingmay be related to a growing chorus ofvoices which are demanding action oncigarette butt litter. A recent newsletterby the David Suzuki Foundation, a well-known science-based Canadian environ-mental organisation, noted that, ‘‘Fromstart to finish, cigarettes are bad for theenvironment. Tobacco production usesland that could support food crops orforests, and pesticides used on tobaccofarms harm workers and pollute the soiland water. An incredible amount of fuel isneeded to dry tobacco... At least 4.5trillion non-biodegradable filter cigarettebutts are discarded around the worldevery year.’’

By trying to portray itself as a responsiblecorporate citizen environmentally, Imperialmay be attempting to get ‘‘out front’’ on theissue, before the chorus of voices demandingaction on tobacco-product-related litterbecomes a roar which governments can nolonger afford to ignore.

Progress on cigarette butt litter is foundin both Edmonton and San Francisco seethis issue, page 255 where mayors therehave recently said it would be worthwhileto levy a tax on tobacco products to helpoffset the clean up costs related tocigarette butts. Meanwhile, city officialsin Ville Marie, a downtown borough inMontreal, have begun enforcing a two-year-old public cleanliness bylaw and areissuing C$169 (US$149) tickets to smo-kers who discard their cigarette butts onstreets and sidewalks.

Attempts to give themselves a greensheen are not uncommon among tobaccocompanies. The industry has surely noticedan upswing in concern for the environmentby citizens in Canada and around theworld, largely due to scientific findingsrelated to climate change. For example,annual reports to shareholders by JapanTobacco (and other multi-nationals) havedetailed the company’s efforts to reducethe greenhouse gas emissions associatedwith its operations.

Most people aren’t fooled, however,and can see through the green sheen.The headline in the Star article says it all:‘‘Smokes: first you’ll feel green, and thenyou’ll die.’’

TREVOR HACHENon-Smokers’ Rights Association, Canada

thache@nsra-adnf.ca

USA/WORLD: TOP CDC CHOICE APPLAUDEDPublic health professionals in the UnitedStates and around the world have beenpraising President Obama’s announce-ment in May that he has chosen DrThomas R Frieden, New York City’shealth commissioner, to be the nextdirector of the Centers for DiseaseControl and Prevention—CDC. DrFrieden is a public health doctor bestknown for his pioneering work to makeNew York a substantially smoke-free city,under the leadership of mayor Michael RBloomberg. In addition, he has first handexperience of working in low incomecountries, which given CDC’s interna-tional programmes and influence, cannotbut be good news for global tobaccocontrol.

Many also see this appointment asgiving hope for a new beginning for USpolicy on tobacco. Despite ground-break-ing progress by individual states, countiesand cities, the USA has for decades evadedserious tobacco control leadership at thefederal level. While the Bush administra-tion spent more than $50 billion on anti-bioterrorism initiatives, for example, itseemed less concerned by the more than400,000 annual deaths from tobacco.When appointed to the New York postshortly after the ‘‘9/11’’ terrorist attacks,and asked about challenges such asbioterrorism in contrast to his stated

This lung cancer warning from Mauritius,showing a healthy lung beside a smoker’s lung,is one of many illustrations in the new healthwarnings report.

Canada: in this ad, published in the June 2009edition of Toronto Life magazine, BAT’sCanadian subsidiary, Imperial Tobacco Canada,indicates what it claims are environmentallyfriendly improvements to its du Mauriercigarette pack, while getting some promotioninto the bargain.

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intention of prioritising anti-smokinginitiatives, Dr Frieden replied,‘‘Bioterrorists are not going to kill moreNew Yorkers than tobacco.’’

USA: NURSES QUIZ DIRECTORSThe first Philip Morris International(PMI) annual stockholders’ meeting washeld on 5 May at the Grand Hyatt Hotelin New York City. PMI is the largesttobacco company in the United States,manufacturer of Marlboro, the world’smost successful cigarette brand, and ownsseven of the world’s largest 20 tobaccocompanies. The chairman and chiefexecutive officer, Louis C Camilleri, notedin his opening remarks to shareholdersthat the key achievement of 2008 hadbeen PMI’s successful spin-off from AltriaInc, and that the company continued tobe committed to high financial returns.

Analysts, however, note that thetobacco industry is being forced to wrestlewith adverse global economic forces,including litigation and government reg-ulation, increasingly imposed smokingrestrictions, and health concerns relatedto the use of tobacco products and toexposure to environmental tobaccosmoke. In other words, to keep up thesehigh fiscal returns, tobacco companiesneed to find more smokers.

Activists from around the world onceagain came together at the shareholders’meeting to protest about youth beingtargeted by the tobacco industry as adeveloping market. I attended the meet-ing with two other nurses, as members ofthe Nightingales Nurses, a group thatworks to educate other nurses and thepublic about the role of the tobaccoindustry in creating disease. For six yearswe have challenged the tobacco industryby attending various tobacco companyshareholder meetings and presenting thetruth about the effects of the companies’products (see, inter alia, USA: nightingalessing at PM’s AGM. Tob Control 2004;13:218).

Before the meeting, we held signs anddistributed information to passers-by dur-ing rush hour on one of New York’sbusiest streets. We joined representativesfrom anti-smoking organisations andwatchdog groups including CorporateAccountability International, EssentialAction, the Campaign for Tobacco-FreeKids and Rebel for an international day ofaction. The New York City Police chal-lenged us to keep away from the hotelentrance and shareholders ‘‘for our ownsafety.’’ Later, as we attended the meetingwith proxy votes, we listened to MrCamilleri’s remarks and waited for the

question and answer period. Rules calledfor comments to be limited to twominutes and to avoid social commentary.During the one hour period three of thosewho approached the microphone congra-tulated the chief executive officer on hisfinancial success, but the rest of thespeakers chose to ask questions designedto show that PMI’s marketing tacticswere not nearly as ‘‘socially responsible’’as the company claimed.

Nancy Wise, Joan O’Connor and I worewhite coats to distinguish ourselves ashealth professionals. We read statementsfrom our patients and their families aboutthe suffering they had endured, and askedquestions designed to make the attendingshareholders acknowledge that their prof-its came at a great human cost. After eachquestion or comment, however, ourmicrophones were cut off, prohibitingany follow-up, which was in itself a formof answer. When I asked if PMI had everpaid a fine related to marketing to youthand if there was any pending litigationconcerning this, Mr Camilleri respondedthat PMI had never paid a fine. We wereunable to get any specific details aboutlitigation.

Jonathan Romo, an activist fromMexico, asked why PMI sponsored rockconcerts if its advertising intent was toget established smokers to change brandsas it claimed, not to entice young peopleto start smoking. Camilleri respondedthat PMI abided by Mexican law andthat the Mexican Federal Commission ofProtection Against Health Risks sent tworepresentatives to the concert to ensurecompliance. However, he had noted inhis opening remarks that one of PMI’sdirectors, Carlos Slim Helu, was unableto attend the annual meeting because ofthe ‘‘current situation in Mexico,’’ refer-ring to the swine ’flu outbreak and theconsequent limits placed on Mexicantravellers.

In her statement, Rachel Kitonyo fromKenya asked Camilleri to stop sellingcigarettes to African children where thegovernments are already overwhelmeddealing with HIV/AIDS, tuberculosis andmalaria. Camilleri’s direct response wasthat ‘‘we don’t market to children’’ andthat in 2008 PMI sold less than 50 millioncigarettes in all of East Africa, none inNigeria for at least a decade and none inKenya. However, a photo of a 2005Marlboro billboard in Nigeria would dis-pute his answer. The CEO ended hisresponse to Kitonyo by thanking her,with what could only be taken assarcasm, for ‘‘coming all the way fromNairobi.’’

For many present, the best question ofthe day came from Ashley Herrin, of theUS group Students Working AgainstTobacco. She prefaced it by saying sherealised that no matter what she asked,Camilleri would probably tell her, as hehad previous questioners, that she was ill-informed or had misunderstood the facts.So instead of a factual question, she askedfor ‘‘a minute of silence on behalf of the5.4 million people who die from tobacco-related illness each year.’’ Camilleri lookedto his right for advice from his associate,who nodded assent. The audience seemedsurprised as the room fell into completesilence. It seemed like a very long NewYork minute before the chief executivetook the next question.

Finally, a short ‘‘feel-good’’ movieabout the Indonesian tobacco companySampoerna was shown. It is estimatedthat seventy per cent of Indonesian mensmoke, but the movie showed mostlywomen working at the company.Husbands and children of the femaleemployees expressed gratitude for thebenefits extended to the families, allowingthem to send their children to school orbegin business ventures of their own.

Tight security at the entrance to themeeting failed to stop six protesters whostood with veils over their faces and raisedsigns showing a wolf in sheep’s clothingto the shareholders and directors attend-ing.

We were a small group facing well-oiled Big Tobacco, but the protest wasgiven critical validation in the BusinessSection of the New York Times the nextday, 6 May 2009, which noted that therewere ‘‘30 dissidents’’ in the crowd of 200.Despite the annual presence of interna-tional protesters, never before had theygained coverage in the mainstream busi-ness press. Thirty may not be a largenumber, to be sure, but this 30 maypossibly have been enough to give

USA: nurses and other protestors outside theannual general meeting of Philip MorrisInternational, in New York City.

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executives and shareholders of PhilipMorris International pause for thought.

CHRISTINE CONTILLONew Jersey, USA

nursemomnj@aol.com

PAKISTAN: BAT SPONSORS CLIMATECHANGE EVENTHealth advocates in Pakistan wereshocked and disappointed by their gov-ernment’s acceptance of British AmericanTobacco’s Pakistan subsidiary, PakistanTobacco Company (PTC), as co-sponsorof a recent government-backed climatechange event. The ministry of the envir-onment apparently saw no incongruity inassociating an industry whose products,more than any other sector’s, destroy thatmost essential part of the environment forsmokers, the human body, with organisedconcern about the external environment.Perhaps the ministry was lulled into afalse sense of normality by the participa-tion of the university of Manchester, UKand the British government itself, throughits High Commission in Pakistan. Action

on Smoking and Health UK has requestedexplanations.

NEPAL: NEWSPAPER’S SPECIAL EDITIONOn the occasion of World No TobaccoDay (WNTD) on 31 May, a weeklynational language newspaper published aWNTD special issue focused on tobaccohealth warnings, emphasising the mes-sage, ‘‘Show the truth, picture warningssave lives.’’ The name of the newspaper,Amalekh, means liberty from variousforms of slavery or dependence in society.Launched in 2006, it is the country’s firsttobacco-free newspaper. The special issue,the first to mark WNTD in Nepal,included editorials on tobacco free culture,smoking in Nepal, the history of tobacco,the impact of health warnings around theworld, with pictures of actual warningsand a calendar for 2009, as well asinterviews with local tobacco controlleaders and a case history of a young lungcancer patient who died last year aged just34. It also contained information aboutdiseases that are caused by smoking, andtips on how to give up.

USA: SMOKERS TO PAY FOR LITTER?The mayor of San Francisco, California,has proposed that an additional state taxshould be added to the price of cigarettesto pay for the litter that smokers leave inthe city’s streets. If passed, it would bethe first such scheme in the United States,where cigarette waste, especially filters,which are not biodegradable, constitutes amajor environmental problem, accountingfor a quarter of all street litter. Initialestimates suggest that the new tax, tocover cleaning costs, may be around 30 UScents per pack.

PAKISTAN: WHO HONOURS DR KHANThe World Health Organization hasawarded a World No Tobacco Day medalto Dr Javaid Khan, a leading chest physicianand tireless campaigner over many years forthe much tougher tobacco control measuresthat his country so badly needs. Despiteheavy teaching duties as professor and headof pulmonary and critical care medicineat the Aga Khan university in Karachi,and onerous clinical work, Dr Khan has

somehow found the time to be a humanwhirlwind of tobacco control activity. Hehas monitored the tobacco industry’s activ-ities, raised tobacco issues at countlessmedical meetings, pressed his governmentfor a tougher, less industry-friendly policyon tobacco, and taken part in countlessmedia activities. All this work has beenmotivated by seeing such frequent examplesof Pakistan’s massive burden of tobaccoinduced disease. But as he told this journalrecently, ‘‘Each time I see a case of lungcancer or chronic obstructive pulmonarydisease, I somehow get extra strength to domore in tobacco control.’’ Among the bestevaluations of his work have been attemptsby tobacco companies to hold ‘‘stakeholder’’discussions with him, which he has declined.

In addition, Dr Khan has repeatedlypublicised the rise of youth smoking,fanned by relentless targeting of youngpeople by a seemingly ever more subtlerange of promotional techniques. He ischairman of the national alliance fortobacco control, a model coalition of keyorganisations and individuals. When theoccasion has demanded it, he hasthought nothing of taking to the streetswith colleagues, all equipped with appro-priate placards, to get across their messagein a way that would have been unthink-able when tobacco control was firstgetting under way in Pakistan just twodecades ago.

Tobacco Control 2009;18:252–255.doi:10.1136/tc.2009.032169

Pakistan: a poster advertising a climate changeevent, bearing the logo of BAT’s Pakistansubsidiary in the lower right hand corner.

Pakistan: Dr Javaid Khan (right) receives hisWHO medal from Pakistan’s health minister, MirAijaz Hussain Jakhrani, watched by WHO’stobacco programme officer in Pakistan, MrShahzad Alam Khan.

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