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Tob Control. 2007 December; 16(6): 363–367.
PMCID: PMC2807357

News analysis

Lebanon: saying it with the packaging

All articles written by David Simpson unless otherwise attributed. Ideas and items for News Analysis should be sent to: d.simpson@iath.org

Despite admissions about the unparalleled dangers of smoking that British American Tobacco (BAT) has been forced to make, some of its marketing activities are as inappropriate as ever. In Lebanon, where it seems to enjoy the government's perpetual dithering, BAT forges ahead with new developments. The latest is a re‐packaging of its Kent brand, with a level of design glitz and hype that must beggar the understanding of those trying to treat patients with tobacco‐related disease in Lebanon's hard‐pressed hospitals.

A toenail curling, cringe making account of the launch, or reveal as it was termed, appeared in a glossy magazine in Beirut. Among the less absurd statements about the new pack was its description by a BAT man as a winning combination of metallic packaging and components to emphasise “quality and luxury, a brand identity of sophistication par excellence”. The magazine's panegyric went on to report that the re‐launch was held in Otium, one of Beirut's top bar–restaurants. “An all white, Zen‐like conceptual setting, coupled with a futuristic podium, stressed the style of Kent. Mini champagne bottles personalised for Kent, fusion finger food to delight the palate, lighting and music to set the mood, the select few invited were drawn into a New York loft atmosphere, for a reveal like no other. Revealed with high tech animations, sound effects and all, the new pack truly spoke for itself.”

Quite enough problems already face Lebanese public health workers trying to reduce their country's large burden of diseases caused by tobacco. With stuff like this still being pumped out by BAT and its friends, how on earth can they persuade the young people who throng Beirut's nightclubs that there is a 50% chance that smoking cigarettes will kill them?

Lithuania: PM tries it on again

Lithuania is the westernmost of the three Baltic states—the others are Latvia and Estonia—and is now a member of the European Union. Remarkable progress has already been made since regaining independence after many years in the former Soviet Union. But while Lithuania appears to be thriving under democracy and a re‐established market economy, it suffers the major disadvantage of being on the receiving end of attention from the tobacco companies.

Philip Morris (PM) has owned a factory in Klaipeda, in the north west of Lithuania, since 1994, the biggest tobacco factory in the Baltic states, where it makes cigarettes for Latvia and Estonia, as well as for local sales. In addition, its holding company, Altria, has a Kraft factory in Lithuania. Not surprisingly, PM has the largest share of Lithuania's cigarette market. Perhaps such relatively large operations and the need to try to persuade the Lithuanian government not to take action that might depress their profitability, are why the company has seemed desperate recently to spend its stockholders' money on public relations stunts.

For some years PM has been among the major sponsors of New Baltic Dance, a prominent feature in Lithuania's cultural events calendar since 1995. The company's persistent efforts to worm its way into the life of the country's non‐governmental organisations (NGOs) are also of concern. On several occasions in recent years, the vigilance of health advocates, in particular those of the national coalition on tobacco and alcohol control, has brought to light activities that must be designed to win political influence.

For example, the health coalition learned that PM, already among the official sponsors of an information centre serving some NGOs in Klaipeda, was organising and sponsoring a youth prevention project, “I can.” Worse, the ministry of education was apparently involved, as were some NGOs. The coalition generated publicity explaining the real intentions of tobacco companies in doing such activities, following which the ministry of education withdrew from the project, which was later abandoned.abandoned.

figure tcna1606.f1
An image of BAT's new Kent packs for sale in Lebanon.
figure tcna1606.f2
India: Mock‐up of a health warning with the skull and crossbones, as originally proposed by the government.
figure tcna1606.f3
Mauritius: cigarettes marked with a skull and crossbones received overwhelming approval in a survey, even by smokers.
figure tcna1606.f4
Mauritius: a Pall Mall cigarette pack from Thailand and one sold in Mauritius: Mauritian smokers strongly supported the idea of their government adopting Thai‐style health warnings.
figure tcna1606.f5
Belgium: Jenga, the game supplied by BAT to Belgian retailers to reward their best customers and a pack of its Bastos cigarette brand.
figure tcna1606.f6
Norway: these cards, each of which has an actual shirt cuff or pocket stuck to them, were left in restaurants and other hospitality venues in Norway this summer, to consolidate publicity about the recent ban on smoking in such locations. Their printed ...
figure tcna1606.f7
Sri Lanka: this board above a shop in a rural area of Sri Lanka says, “We have stopped selling cigarettes for the sake of you and your children.”

Later, another initiative came to light: PM, apparently in collaboration with the economic ministry, was reportedly floating the idea of being allowed to participate in a special market zone with reduced tax rates in Klapeida, designed to attract new businesses rather than to benefit those already established there. Once again, timely publicity probably helped to stop the proposal in its tracks, with the economic ministry issuing a specific denial that any such initiative would take place.

Most recently, in October, PM issued a call for project grant applications for NGOs in the Klaipeda region. PM said it particularly wanted to give financial support to projects promoting social aims, as well as independent activities of NGOs and other, more informal groups. Priority is to be given to projects concerned with the social integration of disabled people, decreasing social deprivation and exclusion, and environmental protection. Needless to say, the health coalition circulated an open letter to NGOs asking them not to apply or participate.

PM does not work alone in its efforts to continue business as usual. For example, Japan Tobacco joined in efforts to persuade the government to implement the World Health Organization's Framework Convention on Tobacco Control (FCTC) more weakly than it proposed. Presumably several tobacco companies are at work behind the scenes at any one time on lobbying activities and recently, what was almost certainly a result of such work, was seen.

Having worked hard with the Ministry of Health to ensure tougher, not weaker FCTC implementation, health advocates are proud of Lithuania now having a smoking ban in bars, restaurants, discos and other places that the industry, at the very least, would like to make exceptions to workplace smoking bans. Indeed, the Lithuanian ban is one of the strongest in Eastern Europe. However, just after the law came into force, the tobacco industry found politicians willing to take up its cause to try for at least a partial reverse. These hired guns are now pushing discussions about the need for smoking rooms. In addition, the tobacco industry also sponsored a study about abolishing the state tobacco and alcohol agency.

As in so many other smaller, independent countries, tobacco control work in Lithuania has to be carried out by busy people who all have other, paid jobs, including doctors in highly demanding and responsible clinical posts. International tobacco control funding agencies please note: for the foreseeable future, Lithuania would benefit greatly from having a dedicated, independent tobacco control agency with a paid staff.

Iceland: a pioneer's saga

When people talk about the history of tobacco control, Norway and Finland are mentioned as the two western countries that pioneered tobacco advertising bans. During the 1980s, these nations' tobacco consumption data was endlessly analysed by other countries striving for a ban. It was also used, selectively of course, by the tobacco industry, desperate to show that the bans had no effect or that somehow they even increased smoking. In fact, another northern European country had got there first: Iceland.

With a population of under a third of a million, it is perhaps unsurprising, if unjust, that less is heard of Iceland than of the countries in other parts of Europe from which it is, geographically at least, relatively remote. In the first half of the twentieth century, few outside Iceland knew much about it. One factor for it beginning to be better known later may have been the award of the Nobel prize for literature in 1955 to its most famous modern writer, Halldór Laxness. He is probably best known for his novel Independent People, a compelling saga of a poor farmer's endurance through thick and often very thin times. That work's title in Icelandic, Sjálfstætt fólk–literally self‐standing people–gives a clue to one of the most important characteristics of Iceland: standing on its own feet, as it were, and doing things in its own way. This is as true in tobacco control as in any other aspect of this unusual nation's achievements.

It is almost 40 years since Iceland placed health warning labels on cigarette packs by law–this was in 1969, when “leaders” such as the UK were still consulting tobacco companies about what texts they might be prepared to print on their packs by “voluntary agreement”, as the infamous system was known. In 1971, Iceland scored its world first when it banned tobacco advertising in mass media, cinemas and outdoors, with 0.2% of total tobacco sales revenue being set aside for tobacco control; but warning labels on packages were no longer mandatory.

After all remaining tobacco promotion was banned in 1977, a national tobacco control committee was established and new proposals were developed. In 1984, the first comprehensive tobacco control act was passed. Warning labels on packages were made mandatory again; sales to minors under 16 were banned; and smoking was restricted in service areas of public and private buildings, in schools, healthcare premises and in public transport and in other workplaces. The total ban on promotion was reaffirmed and made clearer.

Subsequent changes, many still well ahead of most other countries, included provision of help for smokers to quit through primary health care (when 40% of adults aged 18–69 were smoking), smoking bans and restrictions in Icelandic aircraft and ships, and an increase in the proportion of revenue allocated to tobacco control, to 0.7%. An unusual addition in a market economy in recent times was the introduction of tobacco sales licences in 2001. At the same time, all mass coverage of tobacco was banned, other than warnings about its harmful effects; point of sale displays were swept away, with the requirement that tobacco products must not even be visible at the point of sale.

Through all this, smoking prevalence has continued to decline to just under 20.7% for males and 17% for females aged 15–89, down from levels of nearly 30.9% and 28.8%, respectively in 1991.

In June, all bars and restaurants became smoke free, except for those with special, separately ventilated smoking areas. Reaction was highly favourable, to the extent that very few hospitality industry venues have implemented a smoking area. So Iceland now has among the world's most comprehensive tobacco control policies, showing what a small but progressive country can achieve.

India: death of a simple health warning

In recent years, health advocates in India have had something of a roller coaster ride. After years waiting for the thing to get going, at last they were up and away, only to feel that empty, falling feeling as they swooped down again, although still above their starting point. This is nowhere better illustrated than with tobacco pack health warnings.

Having at long last got a superb health minister and, having grown a tobacco control lobby worthy of its size and the massive task in hand, hopes were riding high that the federal government would press ahead with some truly world‐leading warnings. Special factors had been taken into account, the most obvious being language. India, the second largest country in the world, still has large numbers of people who cannot read or write–40% is the commonly accepted figure. In addition, while Hindi is the national language, India must be the ultimate multi‐lingual country: its constitution recognises 22 regional languages, but these also have dialects so, in total, there are more than 100 languages and 200 mother tongues. What sort of health warning could inform the maximum number of people about the unparalleled dangers of smoking?

One answer is to use a graphic image, but with so many who could not read the captions of a disease‐specific image whose gory detail might not be recognisable, is there not a universally accepted danger sign that might warn the maximum proportion of Indians? As in so many countries, there is an answer: the skull and crossbones, not just familiar from the flags of cartoon pirate ships, but widely used on containers of poisonous chemicals and other dangerous products and on electrical installations. Together with graphic images of diseased organs, the government included the skull and crossbones in its wish list. But it was not to be.

In a lengthy period of debate, it emerged that the tobacco industry did not just oppose disease‐related graphic warnings (though some more than others) but was particularly desperate to prevent the skull and crossbones from appearing. This may at first sight appear surprising, but the manufacturers of bidis, the leaf‐wrapped, local product used by millions of lower income smokers, were especially desperate to prevent the government imposing a warning that was particularly effective at reaching their customers.

But how could tobacco interests counter such a simple, universally recognised symbol of poison and danger, especially when it was already part of the government's plans, which meant that an amendment would have to be debated in parliament? The debate generated much favourable comment and media coverage for the government's plans, which should have been quite sufficient for it to stick to its guns. However, a pernicious argument was then wheeled out by industry interests: the skull symbol would be offensive in a religious sense, especially to those people, such as Muslims, who bury their dead.

Public health researchers swung into action. A survey of more than a thousand people not only confirmed that the symbol was the most widely understood to mean danger, especially by less literate, rural people, but also that the religious argument was nonsense. More than nine out of ten Muslims shown the symbol said it would not hurt their religious sensibilities, with only 1.4% saying it would do so. Similar figures for Hindus and followers of other religions showed how baseless it was, but for reasons that may never be known, the industry prevailed and the amendment to remove the skull and crossbones warning was passed. But with proven and growing public and parliamentary support for more effective tobacco control, will the government not show greater political courage and let the roller coaster pick up speed again next time?

Mauritius: poorer people like tough warnings

Another country where health advocates have been researching the acceptability of having a skull and crossbones on cigarette packs, as well as on each individual cigarette, is Mauritius. Health organisation ViSa carried out a detailed survey with people visiting prison inmates, which among other benefits got responses from a sample of the country's less affluent citizens. Both their mocked up packs and cigarettes got highly favourable ratings as to general acceptability, and concurrence with the view that such warnings might help smokers quit and deter those who do not yet smoke from starting. Such ideas would have been unlikely to be taken up by the government in the past when British American Tobacco (BAT), the dominant player in this small country with Africa's highest per capita cigarette consumption, seemed to hold great sway. However, times are changing, and in the face of declining tobacco consumption, BAT recently closed its factory in Mauritius. Perhaps the large sums BAT used to spend on schemes such as its undergraduate scholarship scheme for gifted young people to study at the University of Mauritius may turn out not to have been money well spent.

South Africa: Swedish snus snare

British American Tobacco (BAT) recently sent a delegation of South African members of parliament to Sweden on a “fact finding” trip, to learn about the blessings of snus oral tobacco. The trip was organised by a group called the Association of Reduction of Tobacco‐related Harm (ARTH).

When a draft programme came to light just two weeks before the start of the trip, it revealed that the snus manufacturer Swedish Match and other pro‐snus promoters were to entertain members of the group, who were to stay at the most prestigious hotels and dine at the very best restaurants during their five days in Sweden. Strangely, no tobacco control experts or government officials in Sweden seemed to know anything about the visit until a copy of the draft programme came to the attention of Doctors Against Tobacco (DAT). In order to offer the group a broader picture of Swedish conditions and the snus issue in particular, DAT members then emailed the chairs of the two chambers of the visitors' parliament, inviting the group to a meeting during their stay in Stockholm.

A few days before the group's arrival, DAT was contacted by the South African embassy in Stockholm, expressing the group's strong interest in a meeting. It appeared that efforts to arrange meetings with government officials and snus‐friendly Swedish parliamentarians had been unsuccessful, perhaps in part because of the approaching summer holidays. The visitors were able instead to have a full morning's meeting with Swedish doctors, a health‐friendly Swedish parliamentarian and a youth representative from Sweden's Non‐smoking Generation national youth anti‐tobacco programme. Also present at the “harm reduction by snus” information and discussion session, held at the famous Karolinska University Hospital, were representatives of BAT and ARTH.

BAT has made it clear that it wants to get into the snus market, with South Africa a major target. Swedish health advocates, knowing that the visiting South African delegates might be meeting only pro‐snus advocates from the tobacco industry, were glad to have been able to invite them to a meeting. Perhaps it may have served as a vaccination against any excesses of those who may later have put commercial interests before a balanced, science‐based examination of the complex topic they were studying.

Belgium: retail incentives are child's play

The British tobacco company Imperial Tobacco has been supplying Belgian retailers with an unusual gift with which to reward their loyal customers, presumably to encourage them to buy even more of the company's cigarettes. It is illegal to supply free gifts with tobacco products but so far giving a supply of gifts to retailers, to be handed out to customers at their discretion, has not been challenged by the government.

However, instead of something that might be suitable mainly for smokers themselves, Imperial Tobacco has gone for something rather more homely or at least more appropriate for homes with children. It is a game called Jenga, which normally costs €15–18 (US$21–26). Jenga is a game of physical and mental skill marketed by Hasbro, which describes itself as a worldwide leader in children's and family leisure time entertainment. Players of the game first build a tower from 54 wooden blocks, then take turns to remove them one by one from a layer other than the top one, placing them on top until the tower collapses. The player who caused the collapse is the loser.

By contrast, when children play the game of smoking, the loser is the one who keeps taking the cigarettes, which can cause the eventual collapse of the lung and other organs. This is why tobacco companies say they do not want children to start smoking. But while Jenga is described as suitable for children aged 6 years and above, its packaging has the same colours as Bastos, a leading Imperial Tobacco cigarette brand in Belgium. Whatever can Imperial Tobacco be thinking of?

Canada: health workers agree next targets

Canada has long been a world leader in tobacco control, especially with its early triumphs on banning virtually all promotion and its subsequent triumph over a furious tobacco industry in pioneering graphic health warnings illustrating diseases caused by smoking. One might assume that by now, Canada has done it all. However, tobacco control leaders meeting at their annual conference in Edmonton, Alberta in September took stock of progress to date and focussed on the one major area still requiring attention. It is the need for total protection from second‐hand smoke in all public places and in the workplace. The conference duly set targets for achieving this, as well as for reducing overall tobacco consumption.

Around 700 delegates agreed a national position summary and target list, the Edmonton statement, calling for Canada to become the second smoke‐free country in the Americas (after Uruguay) by the end of 2008. They set a target to reduce Canada's overall smoking prevalence to 12% by 2011. The statement also challenged the government to fulfil its obligations under the World Health Organization's Framework Convention on Tobacco Control (FCTC) and to make Canada a global exemplar of tobacco control by fully meeting all its FCTC obligations, in every province and territory, by 2011. The statement has been sent to the Canadian minister of health and to all the provincial and territorial governments.

Thailand: planning ahead

Last year, 2006, ended with new restrictions on smoking in public places in Thailand, including in transport stations, public parks, at bus stops and in telephone booths. Although there are some places where smoking is still permitted, 36 specific types of location have had smoking prohibited or restricted. There has been heightened activity for smoke‐free places through world no tobacco day and the second conference (COP 2) of the parties of the World Health Organization's Framework Convention on Tobacco Control (FCTC) took place in Bangkok in the summer. Thailand's Dr Hatai Chitanondh was selected as the new conference president to preside over COP 3, to be held in South Africa in 2008.

Despite impressive achievements in 2006 and 2007, next year promises new opportunities, with smoking cessation and tobacco control research the areas likely to get special attention. While Thailand has made rapid tobacco control progress through legislation and regulatory policies, it has been unable to take advantage of the restrictions on public smoking or the research information available because of a lack of infrastructure for population‐based cessation and science‐based collaborative research.

Fortunately, the new Thai health professionals alliance against tobacco brings prospects for progress in these areas. Aided by the new tobacco control research and knowledge management centre of Mahidol University, this alliance of nine health professional groups has been working to build capacity in these areas. Plans are under way for a national smoking cessation “quitline” system. In addition, new opportunities for nicotine and tobacco research are on the horizon through the first Asian regional conference of the Society for Research on Nicotine and Tobacco, SRNT Bangkok 2008, scheduled for 28–31 October.

Stephen Hamann

Thai Health Promotion Foundation, Bangkok, Thailand; stephen@thaihealth.or.th

USA: still welcome in the community

Despite suffering revelations that might have driven other companies out of business, big American tobacco companies still seem to feel as strong and confident as ever in their traditional heartlands. One indication is that they still rub along happily in the feel‐good world of corporate charitable giving, and few seem to see the irony of their executives associating with groups whose work includes picking up the pieces from disease and premature death caused by tobacco.

Latest in the weird world of tobacco company munificence is the case of the chief executive of Reynolds American, Susan Ivey. She is a real high flyer, one of few women bosses in Fortune magazine's list of America's largest corporations. She previously held the top post at Brown & Williamson, having been director of marketing in China for British American Tobacco. She is running the 2007 United Way campaign, a national network of more than 1300 local organisations doing community work, and heads a campaign trying to raise more than $18 million.

The focus of United Way's work is currently education. One of Ms Ivey's more laudable goals, when she is not working on increasing her company's 30% market share, is to involve more women as donors, and no doubt as recipients of good education, too. However, it seems unlikely that effective education about the true facts and figures of tobacco use, especially among young women, will be a feature of any aspect of her work.


Articles from Tobacco Control are provided here courtesy of BMJ Publishing Group