Expansion of the tobacco industry and smuggling: challenges for public health in developing countries

The international tobacco industry, in its constant quest for new markets, has expanded aggressively to middle- and low-income nations. At the same time there has been a marked increase in tobacco smuggling, especially of cigarettes. Smuggling produces serious fiscal losses to governments the world over, erodes tobacco control policies and is an incentive to international organized crime. In addition, smuggling results in increased demand for and consumption of tobacco, which in turn benefits the tobacco companies. Moreover, there is evidence indicating that the international tobacco industry has instigated cigarette smuggling and has participated directly in these activities, while at the same time carrying out costly lobbying campaigns to pressure governments against tax increases and to promote their own interests. Academic studies and empirical evidence show that tobacco control can be promoted through high tax rates without causing significant increases in smuggling. To achieve this tobacco smuggling must be attacked through the use of strategies including multilateral controls and actions such as those included in the Framework Convention on Tobacco Control, which establishes the basis for combating smuggling through an international, global approach. It is also necessary to increase the penalties for smuggling and to make the tobacco industry, including producers and distributors, responsible for the final destination of their exports.     

Turning off the tap: the real solution to cigarette smuggling.

The tobacco industry has argued that tobacco smuggling is caused by market forces, i.e., by the price differences between countries, which create an incentive to smuggle cigarettes from 'cheaper' to 'more expensive' countries, and so urged governments to solve the problem by reducing taxes to remove this differential, which will also, they say, restore revenue. Although such market forces have some effect, smuggling is in fact more prevalent in 'cheaper' countries, and reducing tax is not the solution. Where taxes have been reduced tobacco consumption has risen and revenue has fallen, with disastrous consequences for public health. The key to understanding cigarette smuggling is understanding the role of the tobacco industry. At the heart of cigarette smuggling is large scale fraud: container loads of cigarettes are exported, legally and duty unpaid, to countries where they have no market, and where they disappear into the contraband market. They are often smuggled back into the country of origin, where they are sold at a third to half price. It is therefore profitable because duty has been illegally evaded. The key to controlling cigarette smuggling is not lowering taxes, it is controlling the tobacco manufacturing industry and its exporting practices.     

U.S. Tobacco Taxes: behavioural effects and policy implications

This paper examines U.S. tobacco taxation, the effect of cigarette taxes on smoking and on the health effects of smoking, and equity and efficiency considerations that arise when cigarette excise taxes are used to reduce smoking. Cigarette excise taxes, imposed by the Federal Government, all Stale governments, and nearly 400 cities and counties, add approximately 34 cents per pack to the price of cigarettes. Real cigarette excise tax rates have fallen because tax increases have not kept pace with inflation. Increases in the price of cigarettes decrease smoking, particularly by adolescents. An estimated 100,000 additional persons may live to the age of 65 as a result of doubling the Federal cigarette tax in 1983. Because cigarette taxes are regressive and are borne primarily by smokers, inequities may arise when they are used to reduce smoking. Success in achieving a tobacco-free society will require that tobacco taxes be replaced with alternative sources of revenue.     

Are low income countries targets of the tobacco industry? Plenary lecture given during the Conference on Global Lung Health and 1997 Annual Meeting of the International Union Against Tuberculosis and Lung Disease, Palais des Congrès, Paris, France, 1-4 October 1997.

Estimations show that tobacco consumption is steadily increasing in low income countries already deprived of basic human needs, such as adequate food and water supplies and education. Among the many factors affecting this, the most significant is the aggressive marketing strategies of the tobacco industry. The tobacco industry operates by denying health evidence, sponsoring scientific research that diverts attention to other fields, investing heavily in promotion and advertising, interfering with national public health laws, forming joint ventures with national monopolies, and persuading governments on the risks of smuggling. Turkey, a tobacco-growing country, opened its markets to the multinational tobacco industry after 1984. This paper presents examples of the marketing strategies used by the tobacco industry in the last two decades, and shows the consequences for Turkey in the hope that this information can help other low income countries that are not yet targets of the invasion of the tobacco industry.     

Secondhand smoke: facts and lies

Mexico ratified the Framework Convention for Tobacco Control in 2004 and is obligated to move forward with implementing its provisions, including Article 8 (Protection from exposure to tobacco smoke). The country has already faced opposition from the tobacco industry. This paper addresses industry tactics against tobacco control, describing the general strategies that have been pursued and the evidence relevant to combating these strategies. The approaches taken by the industry in an effort to discredit the scientific foundation for promoting smokefree environments, the efforts by the industry to propose ventilation of indoor spaces and separation of smokers from nonsmokers as an effective alternative to smokefree places, and finally, the strategy of raising fear of economic losses on the part of the hospitality industry and thereby gaining this sector as an ally in campaigning against smokefree policies are considered. As reviewed in this article: 1) There is scientific consensus on the adverse effects of inhaling SHS; 2) Only smokefree places fully protect nonsmokers from inhaling SHS; and 3) Smokefree policies do not bring economic harm to the hospitality industry.     

Government action to reduce smoking

The major health impacts of smoking were established more than 40 years ago but Governments were slow to respond to the growing health epidemic. Despite laudable tobacco control strategies in many countries, globally deaths from smoking continue to rise and are forecast to reach 10 million a year by the 2030's. There is now general agreement that in order to substantially reduce smoking rates, governments need to adopt a comprehensive approach to tobacco control. This should include a range of measures, notably: a total ban on tobacco advertising and promotion; restrictions on smoking in public places and in the workplace; sustained increases in tobacco taxation combined with measures to curb smuggling; large, bold health warnings on tobacco products; smoking cessation and health education campaigns; and the regulation of tobacco to standards agreed by the health community rather than those set by the tobacco industry. While legislation is to be favoured over voluntary controls, the key to the successful implementation of these measures is winning public support and ensuring proper enforcement. Given the enormous burden that smoking places on health services, governments in developed nations have generally responded by introducing a range of tobacco control measures. However, the picture is far from uniform and some of the best examples of strong, government-led action have occurred in less developed nations. Governments can learn much from these countries and, by supporting the impending global treaty on tobacco control, can help to reduce the smoking-related diseases and deaths of the future.     

The quest to expand the coverage of public health insurance in the occupied Palestinian territory: an assessment of feasibility and sustainability using a simulation modelling framework

Background

In their quest for universal health coverage (UHC), many developing countries explore alternative financing strategies to address the potential budgetary impact of health coverage expansion (for example, deferred debt versus current finance through taxation or premiums). Given the limited fiscal space, these policies may have different implications for fiscal sustainability and may worsen intergenerational inequality.

E-Cigarettes: A New Threat to Cardiovascular Health – A World Heart Federation Policy Brief

Tobacco is widely recognized as a leading cause of cardiovascular morbidity and mortality, accounting for approximately seventeen percent of all cardiovascular disease deaths globally. Electronic nicotine delivery systems such as e-cigarettes have been developed and advertised as safer alternatives to traditional tobacco cigarettes. Aggressive marketing strategies, as well as misleading claims by manufacturers, have largely contributed to the belief that e-cigarettes are harmless.In reality, e-cigarettes are far from innocuous. E-cigarette solutions and aerosols generally contain harmful substances that are commonly found in tobacco cigarette emissions. A growing body of literature suggests that e-cigarettes are associated with an increased risk of cardiovascular morbidity and mortality. In addition, the effectiveness of e-cigarettes as smoking cessation tools has yet to be determined. Concerningly, most smokers do not give up on tobacco cigarettes and eventually become dual users.Unregulated, e-cigarettes constitute a serious threat to established tobacco control policies. Fortunately, many countries have demonstrated that strong regulations were effective in protecting their populations from the dangers of e-cigarettes. The World Heart Federation recommends applying the precautionary principle and a set of measures to protect vulnerable populations, prevent exposure to second-hand smoking, and address misleading claims.In this regard, we recommend that governments, policymakers, and other relevant stakeholders enact or support the following measures, among others:

• Prohibit the sale and distribution of e-cigarettes to minors, as well as the use of flavouring agents.
• Prohibit the use of e-cigarettes anywhere tobacco cigarettes have been banned.
• Prohibit marketing, advertising, and misleading claims regarding e-cigarettes.
• Apply excise taxes on e-cigarettes.
• Conduct more research regarding the long-term effects of e-cigarettes on cardiovascular health.

Lastly, countries that have banned the commercialization of e-cigarettes should maintain these measures.     

Social responsibility argument for the tobacco industry in Brazil

The issue of "corporate social responsibility" has been one of great importance and concern in the world and has received different names, such as social responsibility, corporate citizenship, sustainable development and corporate ethics. Today, more than ever, it has been necessary for governments, as well as the diverse representatives of "organized civil society," to act in accordance with the concept of sustainable development. This implies an understanding that preservation of the environment, health and education is related to economic productivity; it means an understanding that healthy populations are essential to the reduction of poverty, as well as economic growth and sustainable development. The various positive experiences in Brazil in confronting the tobacco industry's strategies to undermine national tobacco control efforts are due to the existence of a wide network that has played a fundamental role in social control with respect to both the monitoring of public policies that control tobacco and tobacco industry strategies.     

"Plain packaging" regulations for tobacco products: the impact of standardizing the color and design of cigarette packs

Tobacco packaging and labeling policies have emerged as prominent and cost-effective tobacco control measures. Although packaging policies have primarily focused on health warnings, there is growing recognition of the importance of packaging as a marketing tool for the tobacco industry. The current paper reviews evidence on the potential impact of standardizing the color and design of tobacco packages -so called "plain" packaging. The evidence indicates three primary benefits of plain packaging: increasing the effectiveness of health warnings, reducing false health beliefs about cigarettes, and reducing brand appeal especially among youth and young adults. Overall, the research to date suggests that "plain" packaging regulations would be an effective tobacco control measure, particularly in jurisdictions with comprehensive restrictions on other forms of marketing.     

Content analysis of tobacco industry data on the illicit tobacco trade in UK newspapers during the standardised packaging debate

BackgroundStandardised tobacco packaging, which commenced in the UK in May, 2016, has been vehemently opposed by transnational tobacco companies. Previous research has concluded that companies invoke the existence of an illicit trade in tobacco to oppose tobacco control policies and exaggerate its true scale. The argument they make is that such policies will further increase this trade. Independent peer-reviewed evidence does not support claims that illicit tobacco increased after the 2012 implementation of standardised packaging in Australia. In the UK, leaked Philip Morris International documents revealed the tobacco company's intention to utilise third-party “media messengers” to make the argument that the policy will exacerbate the illicit tobacco trade. We aimed to explore whether and, if so, how, transnational tobacco companies presented their data on illicit tobacco in UK newspapers during the standardised packaging policy debate and whether Philip Morris implemented its media messengers plan.MethodsArticles about illicit tobacco published in English language UK newspapers from April 1, 2013, to March 31, 2015, from LexisNexis were examined for presence, nature, and timing of tobacco industry data, which included any illicit tobacco monitoring initiative commissioned or undertaken by transnational tobacco companies in the UK or overseas. Search terms included combinations of “illegal”, “illicit”, “smuggling”, “tobacco”, “cigarette”, all four transnational tobacco companies, and known tobacco industry consultants.Findings428 articles about illicit tobacco were identified. 157 articles (37%) cited industry data, of which 90 (57%) referred to undercover test purchases, the remainder citing data from empty pack surveys, seizures, polls, or data of unknown methodology. 98 (62%) of the 157 articles mentioned ex-Scotland Yard Detective Chief Inspector Will O'Reilly, who conducts undercover test purchases for Philip Morris International; in 34 of these articles, this funding was not disclosed. Most articles were published in regional newspapers (77%, 121/157) and the majority mentioned counterfeit tobacco, so-called cheap whites, or both (72%, 113/157). However, the Institute of Trading Standards revealed that between May and November, 2014, over 70% of the illegal tobacco seized was tobacco industry contraband.InterpretationPhilip Morris International's investment in undercover test purchases appears to have enabled the tobacco industry to secure significant press coverage of its data on illicit tobacco. With over half of the articles in this study referring to a consultant working on behalf of the tobacco company, its plan to use third party media messengers as part of its anti-standardised packaging strategy appears to have been mobilised. Industry-funded third party spokesmen, notably former policemen, are now appearing in other countries, suggesting that this is an industry tactic that should be expected in other jurisdictions. Transparency in all media coverage is essential.FundingKAE-R is supported by Cancer Research UK (C27260/A20488). JLH is supported by the UK Centre for Tobacco and Alcohol Studies (MR/KO23195/1). AR is supported by the New Venture Fund.     

A proposed approach to systematically identify and monitor the corporate political activity of the food industry with respect to public health using publicly available information

Unhealthy diets represent one of the major risk factors for non‐communicable diseases. There is currently a risk that the political influence of the food industry results in public health policies that do not adequately balance public and commercial interests. This paper aims to develop a framework for categorizing the corporate political activity of the food industry with respect to public health and proposes an approach to systematically identify and monitor it. The proposed framework includes six strategies used by the food industry to influence public health policies and outcomes: information and messaging; financial incentive; constituency building; legal; policy substitution; opposition fragmentation and destabilization. The corporate political activity of the food industry could be identified and monitored through publicly available data sourced from the industry itself, governments, the media and other sources. Steps for country‐level monitoring include identification of key food industry actors and related sources of information, followed by systematic data collection and analysis of relevant documents, using the proposed framework as a basis for classification of results. The proposed monitoring approach should be pilot tested in different countries as part of efforts to increase the transparency and accountability of the food industry. This approach has the potential to help redress any imbalance of interests and thereby contribute to the prevention and control of non‐communicable diseases.     

Alcohol, Tobacco and Public Policy: the contribution of economics

This article shows the contribution of economics to debates about prevention policy. The arguments used by various pressure groups favouring or opposing more effective prevention policies need to be subject to critical scrutiny and empirical testing. The market failure case for state intervention in alcohol and tobacco markets is assessed and an alternative public choice approach is outlined. The supply side of the market in the form of the alcohol and tobacco industries is analysed using a structure-performance framework. Consideration is given to how firms might respond to prevention policies through, say, lobbying or shifting higher taxes to suppliers or by diversifying into new markets.     

Global perspective on tobacco control. Part II. The future of tobacco control: making smoking history?

Serious efforts to reduce the harm caused by tobacco use throughout populations require implementation policies and interventions capable of reaching all smokers and potential smokers. While the Framework Convention on Tobacco Control promises to accelerate the adoption of comprehensive tobacco control policies throughout the world, its extensive 'optional' language provides considerable latitude for governments unwilling to implement rigorous controls. This paper examines four broad areas in which important debates and policy advances will be necessary to ensure population-wide impact of tobacco control: harm reduction; demand reduction strategies involving particularly the use of news generation in increasing the coverage of tobacco and health issues; denormalisation of tobacco use, especially among health workers in nations where use remains high; and further efforts to regulate the tobacco industry, particularly in regard to plain packaging, under-the-counter retail sales and the regulation of tobacco products.     

The effect of tobacco control policies on smoking prevalence and smoking-attributable deaths. Findings from the Netherlands SimSmoke Tobacco Control Policy Simulation Model

Aim To develop a simulation model projecting the effect of tobacco control policies in the Netherlands on smoking prevalence and smoking‐attributable deaths. Design, setting and participants Netherlands SimSmoke—an adapted version of the SimSmoke simulation model of tobacco control policy—uses population, smoking rates and tobacco control policy data for the Netherlands to predict the effect of seven types of policies: taxes, smoke‐free legislation, mass media, advertising bans, health warnings, cessation treatment and youth access policies. Measurements Outcome measures were smoking prevalence and smoking‐attributable deaths. Findings With a comprehensive set of policies, as recommended by MPOWER, smoking prevalence can be decreased by as much as 21% in the first year, increasing to a 35% reduction in the next 20 years and almost 40% by 30 years. By 2040, 7706 deaths can be averted in that year alone with the stronger set of policies. Without effective tobacco control policies, almost a million lives will be lost to tobacco‐related diseases between 2011 and 2040. Of those, 145 000 can be saved with a comprehensive tobacco control package. Conclusions Smoking prevalence and smoking‐attributable deaths in the Netherlands can be reduced substantially through tax increases, smoke‐free legislation, high‐intensity media campaigns, stronger advertising bans and health warnings, comprehensive cessation treatment and youth access laws. The implementation of these FCTC/MPOWER recommended policies could be expected to show similar or even larger relative reductions in smoking prevalence in other countries which currently have weak policies.     

Trial registration for public trust: making the case for medical devices

Recently, several pharmaceutical companies have been shown to have withheld negative clinical trial results from the public. These incidents have resulted in a concerted global effort to register all trials at inception, so that all subsequent results can be tracked regardless of whether they are positive or negative. These trial registration policies have been driven in large part by concern about the pharmaceutical sector. The medical device industry is much smaller, and different from the pharmaceutical industry in some fundamental ways. This paper examines the issues surrounding registration of device trials and argues that these differences with pharmaceutical should not exempt device trials from registration.     

Pushing up smoking incidence: plans for a privatised tobacco industry in Moldova

Moldova, one of the former Soviet republics and Europe's poorest country, has so far resisted pressure to privatise its tobacco industry. This paper examines the policies pursued by the transnational tobacco companies in Moldova in order to inform the ongoing debate about tobacco industry privatisation. We analysed relevant internal industry documents made public through litigation. The documents suggest that although a competitive tender for the state owned monopoly was later announced, British American Tobacco (BAT) and the German manufacturer Reemtsma each initially sought to secure a closed deal, with BAT accusing Reemtsma of underhand tactics. Imperial Tobacco, which now owns Reemstma, was unable to comment on these allegations as it only acquired Reemstma after the events in question. BAT sought to acquire a monopoly position, bolstered by excise rules developed by the company that would uniquely favour its products. Despite hoping to establish a monopoly, it planned intensive marketing, as if in a competitive market, aiming to target young urban dwellers, particularly opinion leaders. In so doing it predicted that smoking uptake would increase, especially among women. The documents also suggest that BAT was aware of the sensitive nature of its plans to cull the processing workforce and aimed to present "sanitised" information on future employment levels to the Moldovans. The potential for tobacco industry privatisation to undermine tobacco control and promote cigarette consumption is highlighted and is consistent with economic theory. Countries planning tobacco industry privatisation should ensure a transparent and competitive privatisation process, seek to prevent the predicted increase in consumption by implementing effective tobacco control policies and consider the impacts on employment. Multilateral financial organisations promoting tobacco industry privatisation could ensure their loan conditions protect public health by making the implementation of tobacco control policies a pre-requisite for privatisation.     

Tobacco control in China: the dilemma between economic development and health improvement

Although China's National People's Congress announced its decision to ratify the WHO's Framework Convention on Tobacco Control (FCTC) on Sunday, August 28, 2005, fundamental challenges to tobacco control still exist. A survey at the "No Smoking Day" on May 31, 2004 in China showed that over 73% of respondents do not think that human society will be able to get rid of the consumption of tobacco products. Although the prevalence of smoking declined 1.2% from 1996 to 2002, the absolute number of smokers increased by 30 million during this period. It is estimated that smoking prevalence will decline 10% in the next 25 years. However, due to the population increase, the total number of tobacco consumers will be about the same as today, which is 320 million. As long as the tobacco industry continues to be significant in overall economic development, and as long as the government continues to play a significant role in tobacco production, the debate between tobacco production and tobacco control will continue. Although China has already made significant efforts with regard to tobacco control, it is still in the beginning of its "long march" towards improving the population's health status by reducing tobacco consumption in China.     

Smoking and economic incentives in Europe

This paper reviews the agenda for economic research near the beginning of a formative period for policy marked by much greater involvement by the EC (European Community). There are few signs as yet of any diffusion process at work in Europe to bring about reductions in smoking. Effective use of incentives will be needed to bring about reductions in smoking by 2000 and to stop yet further massive increases in mortality from smoking related disease. Research is needed on price and income elasticities in Europe as the EC introduces new policies for raising cigarette taxes and prices. Currently most estimates are based on US and UK data. There is also an important research agenda on the decision-making process in Europe covering the policy response of national governments and professions as well as the future role of the EC Commission. Finally, research is needed on the micro-economic determinants of the demand for tobacco products across Europe by households. Household data from family expenditure surveys are now available across Europe so that it is now possible to construct micro demand systems for each European country.     

Joint impacts of minimum legal drinking age and beer taxes on US youth traffic fatalities, 1975 to 2001

Background: There is a considerable body of prior research indicating that a number of public policies that limit alcohol availability affect youth traffic fatalities. These limitations can be economic (e.g., beverage taxation), physical (e.g., numbers or operating hours of alcohol outlets), or demographic (e.g., minimum legal drinking age). The estimated impacts of these policies differ widely across studies. A full‐price theoretical approach suggests that people weigh the benefits of drinking against the sum of all the associated costs, including the price of the beverages themselves plus the difficulty of obtaining them and any additional risks of injury or punishment related to their use. This study tested one prediction of this model, namely that the impact from changing one availability‐related cost depends on the level of other components of full cost. Methods: The current analyses concentrate on 2 forms of limitations on availability that have been shown to affect youth traffic fatalities: minimum legal drinking age (MLDA) laws and beer taxes. The interdependence between the impacts of MLDA and taxes is investigated using a panel of 48 US states over the period 1975 to 2001. All age‐group–specific models control for numerous other variables previously shown to affect vehicle fatalities, as well as fixed effects to account for unexplained crosssectional and time‐series variation. Results: The analyses showed that raising either MLDA or beer taxes in isolation led to fewer youth traffic fatalities. As expected, a given change in MLDA causes a larger proportional change in fatalities when beer taxes are low than when they are high. Conclusions: These findings suggest that a community's expected benefit from a proposed limitation on alcohol availability depends on its current regulatory environment. Specifically, communities with relatively strong existing policies might expect smaller impacts than suggested by prior research, while places with weak current regulations might expect larger benefits from the same policy initiative.