TOOLS FOR ADVANCING TOBACCO CONTROL IN 21ST CENTURY SUCCESS STORIES AND LESSONS LEARNED BOOKLETS

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Title
TOOLS FOR ADVANCING TOBACCO CONTROL IN 21ST CENTURY SUCCESS STORIES AND LESSONS LEARNED BOOKLETS
extracted text
WHO/NMH/TFI/FTC/03,4

Taxation (including
Smuggling
Control)

RF_PH_15_SUDHA

Tobacco Excise Taxation in South Africa

Tobacco Free Initiative would like to thank
the Centers for Disease Control and Prevention (CDC), Atlanta, USA

for their generous support for this project.

© World Health Organization 2003

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Printed in World Health Organization, Geneva.

Tobacco Excise Taxation
in South Africa
Corne van Walbeek
University of Cape Town, South Africa

World Health Organization

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

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Tobacco Excise Taxation in South Africa

Introduction

decreased by 70 per cent. This rapid decrease occurred
despite calls by the medical community and the Ministry

The past ten years have witnessed a major turnabout in

government policy on tobacco control in South Africa.
Within a relatively short time, government policy has

changed from complete apathy to one where the tobacco

control measures are regarded as some of the most pro­

gressive in the world.

of Health to increase the excise tax.

In 1994 the African National Congress became the domi­
nant party in the Government of National Unity after the
first democratic elections. In the early 1990s the outgoing
government had started introducing some tobacco con­

trol measures, in the form of legislation mandating health

South Africa's tobacco control policy rests on two impor­

warnings, and increases in the excise tax. In 1993 the ANC

tant pillars: legislation and excise tax increases. In 1999

announced that it would accelerate the tobacco control

the government passed legislation that banned tobacco

advertising and sponsorship, prohibited smoking in all pub­

lic places (including workplaces), and banned the sale of

tobacco to minors. This legislation was an amendment to

an act passed in 1993 that prohibited smoking on public
transport and introduced health warnings for the first time.

measures if it came to power.

The new government made its intentions clear at the
reading of the Budget in June 1994, when the Minister of

Finance announced that the government would increase

the tax on tobacco products to 50 per cent of the retail
price.1 At that point, excise taxes amounted to 21 per cent

As well as increasing the implicit costs of smoking, the

of the retail price and the total tax burden (i.e. including

legislation prohibiting smoking in public and work places

sales tax) was 32 per cent of the retail price. However,

represents a clear transfer of property rights from smok­

after being pressurised by the industry, the government

ers to non-smokers. Whereas previously smokers enjoyed

opted for a slower phasing in of the adjustment. While

the right to pollute the air, the legislation unambiguously

the phasing in approach was a temporary setback for the

assigns non-smokers the right to unpolluted air. Although

tobacco control lobby, the government kept to its prom­

the direct impact of the legislation on tobacco consump­

ise, increasing the excise tax by substantially more than

tion is still unclear, the legislation has continued the trend

the inflation rate at subsequent readings of the Budget. In

of deglamorising smoking in South Africa. As a result,

1997 the Minister of Finance announced that the 50 per

smoking is no longer regarded as socially acceptable by

cent target had been achieved. Subsequent tax increases

large sections of the population.

were aimed at keeping the tax percentage at that level.

In the past decade the government has substantially

Some trends regarding tobacco taxation in South Africa

increased the excise tax on tobacco products for health

are shown in Table 1. Column (f) illustrates the rapid

reasons. Since 1994 the nominal tax on cigarettes has

decrease in real excise tax between 1970 and the early

increased by nearly 25 per cent each year. Econometric

1990s, followed by a sharp increase subsequently. A

evidence indicates that the resulting price increases have

recent study has shown that, in the past decade, South

had a significant impact on cigarette consumption. The

Africa has had the third highest percentage change in

aim of this paper is to investigate tax increases in some

tobacco taxes (after Korea and France) amongst 90 coun­

detail.

tries. It is interesting that, despite the industry's protes-

Description of the Intervention*
In South Africa, as in many countries, the excise tax is

During the 1970s and 1980s tobacco control was not on

levied as a specific tax, i.e. a certain amount per pack of

the public agenda. The tobacco industry used its cordial

cigarettes. Unless the tax is adjusted regularly, inflation

relations with the government to prevent any measures

will erode the tax. This is exactly what happened in South

that would harm the industry. On tobacco issues, the

Africa during the 1970s and 1980s.

government regularly consulted the industry. For exam­

ple, before the budget was presented to Parliament

However, even though the excise tax is technically a spe­

the tobacco industry was consulted about possible tax

cific tax, the government's policy of setting the tax at 50

increases. Not surprisingly, the tax increases were generally

per cent of the retail price has turned it into a de facto ad

very modest. In fact, between 1970 and the early 1990s

valorem tax.

the real (i.e. inflation adjusted) excise tax on cigarettes

3

World Health Organization

Table 1
Trends in cigarette prices, taxes and consumption'

Year

Cons,
millions
of packs

Price,
Nominal,

Price,
Real,
1995
base,

Excise
tax,
Nominal,

Excise
tax,
Real,
1995
base,

Cents
per pack

Cents
per pack

Cents
per pack

Cents
per pack

Excise
tax as
% of
price

Total
tax as %
of price

(h)

Industry
price,
Real,
1995
base,

Excise
revenue,
Real, 1995
base,

Cents
per pack

R millions

(a)

(b)

(e)

517

(c)
19.1

(d)

1961

449

9.1

(f)
214

(g)
47.6%

47.6%

(i)
235

(j)
1106

1965

608

19.4

417

9.1

196

46.9%

46.9%

222

1189

1970

783

22.1

405

11.1

203

50.2%

50.2%

202

1975

1048

31.8

373

14.6

171

45.9%

45.9%

202

1795

20.1

134

41.0%

44.9%

181

1725

1593

1980

1283

49

328

1981

1443

53

308

20.1

117

37.9%

41.8%

179

1684

1982

1632

62

314

21.1

107

34.0%

39.1%

191

1745

1983

1551

66

298

24.1

109

36.5%

42.2%

172

1686

1984

1570

74

299

24.6

99

33.2%

41.0%

176

1560

1985

1571

84

292

26.1

91

31.1%

41.4%

171

1425

1986

1591

94

276

26.1

77

27.8%

38.5%

170

1217

1987

1671

109

275

26.1

66

23.9%

34.7%

180

1101

1988

1795

122

273

27.1

61

22.2%

32.9%

183

1089

1989

1809

138

269

30.6

60

22.2%

33.5%

179

1079

1990

1868

165

281

33.1

56

20.1%

31.6%

193

1055

1991

1927

171

253

37.6

56

22.0%

32.9%

170

1072

1992

1900

222

288

44.6

58

20.1%

29.2%

204

1100

1993

1802

255

302

53.2

63

20.9%

31.3%

204

1135

1994

1769

284

309

60.5

66

21.3%

33.6%

205

1162

1995

1708

348

348

75.3

75

21.6%

33.9%

230

1287

1996

1690

387

360

92.0

86

23.8%

36.1%

230

1447

1997

1577

497

426

117.5

101

23.6%

35.9%

273

1588

1998

1495

608

487

169.5

136

27.9%

40.2%

292

2032

1999

1422

730

558

214.3

164

29.3%

41.6%

325

2332

2000

1333

803

582

254.5

184

31.7%

44.0%

326

2453

2001b

1272

889

608

291.5

199

32.8%

45.1%

334

2540

■ Sources: Auditor-General, Statistics South Africa (previously Central Statistical Services and Department of Statistics), Budget Review, Tobacco Board.

b Preliminary figures.

4

Tobacco Excise Taxation in South Africa

0

Table 2
Nominal percentage changes in the excise tax on various tobacco products3

Financial year

Cigarettes

Cigarette

Pipe tobacco

Cigars

Inflation rate

12.0

tobacco

1990/1

11

11

10

13

1991/2

14

14

11

14

11.4

1992/3

8

8

4

5

8.3

1993/4

9

19

2

2

9.7

1994/5

25

29

25

30

9.0

1995/6

24

27

25

28

8.7

1996/7

18

20

18

19

7.4

1997/8

52

56

52

53

8.6

1998/9

29

31

29

29

6.9

1999/00

20

85

166

3669

5.2
5.4

2000/1

16

40

56

74

2001/2

12

12

20

17

5.7

Average 1990/1

11

13

7

9

10.4

25

38

49

490

7.1

20

29

35

330

8.2

- 1993/4
Average 1994/5

- 2001/2
Average 1990/1
- 2001/2
• Source: Budget Review

tations about the "unreasonableness" of the excise tax
1 However, during the 1960s cigarettes, like all goods, were

not subject to sales tax. The imposition of sales tax, since

increases, the real excise tax in 2001 is no higher than the

level of the 1960s.2 Total tax as a percentage of the retail

the late 1970s has increased the effective tax burden

price follows a similar trend, as indicated in column (h).

above the level of the 1960s.

The tax proportion decreased from 50 per cent in 1970 to

3 Since 1997 the Ministry of Finance has claimed that it has

30 per cent in 1992, after which it rose to 45 per cent in

achieved the 50 per cent tax target. This is more illusion-

2001 ? Despite the excise tax increases, the tax proportion

ary than real. When the Ministry calculates the tax inci­

of South African cigarettes, compared to many Western

dence percentage, the denominator they use is the retail

countries, is still low.

price before the tax increase. This is unrealistic. The tax

increase causes the retail price to increase, with the result

The real retail price of cigarettes has more than doubled

that the denominator increases. So, ex post, the total tax

over the past decade, as is shown in column (d). This

percentage is much lower than the claimed 50 per cent, as
is illustrated by column (h) of Table 1.

means that cigarettes, in comparison to a basket of other

goods and services, have become very expensive. In fact,

of all commodities surveyed by the South African statistical

5

World Health Organization

authorities, cigarettes have been subject to the largest price

Implementation

increases over this period. This was a dramatic reversal
of the previous 20 years' trend, since between 1970 and

In contrast to tobacco control legislation, which has to go

the early 1990s the real price of cigarettes had fallen by

through a lengthy parliamentary process, it is very easy to

a third. At purchasing power parity, the price of South

increase the excise tax on tobacco products. Even before

African cigarettes is currently comparable to those of many

1994, the Minister of Finance announced increases in the

European countries and Japan.

tobacco excise tax at the annual reading of the Budget.

In South Africa cigarettes represent more than 90 per cent

of tobacco sales. Some of the poorer sections of society
buy pipe and cigarette tobacco and roll their own ciga­

However, as pointed out, the increases were small and

usually less than the inflation rate.

In South Africa a vocal tobacco control lobby, led by the

rettes. However, despite the large increases in the real

Medical Research Council (MRC) and the National Council

price of cigarettes, the non-cigarette tobacco segment has

Against Smoking (NCAS), had been arguing for significant

remained small.

tax increases since the 1970s. They appealed for a com­

In order to be effective, tobacco excise tax increases
should not create incentives for people to shift their

tobacco consumption from one form to another. The tax

increases should thus be similar for the various tobacco

products. In Table 2 the percentage changes in the excise
tax for the four excisable tobacco products are shown.

In most years the tax increases on potential substitutes
to cigarettes (i.e. pipe and cigarette tobacco) have been
similar to that of cigarettes, but in some years, notably

1999 and 2000, the tax increases have been substantially
greater. This suggests that the government was aware of
the possible substitutability of tobacco products, and did

prehensive tobacco control strategy resting on three basic

pillars: (1) an advertising ban, (2) restrictions on smoking
in public places, and (3) rapidly increasing tobacco taxes.

They pointed out that international evidence had shown
that increasing the excise tax on tobacco is the most effec­
tive tobacco control measure. Despite the fact that tobac­

co is addictive, numerous studies, performed in a variety

of countries, have shown that excise-induced increases in
tobacco prices causes tobacco consumption to decrease.
They also pointed out that international experience had

clearly shown that increasing tobacco excise taxes also
increases government revenue.

not want to create an incentive for consumers to switch to

The tobacco control lobby wanted the government to ear­

substitutes.

mark a proportion of the tobacco excise taxes for general

An important omission is snuff, which is not taxed at all.

According to the National Council Against Smoking, in

South Africa, almost as many women use snuff as smoke
cigarettes. Despite tobacco control groups lobbying for a

tax on snuff, no tax has been imposed to date.

In South Africa the excise tax on cigars has traditionally
been very low. However, this changed dramatically in

1999 when the excise tax was increased nearly forty-fold.

This was followed by another 74 per cent increase in the
excise tax in 2000. The Minister of Finance claims that

the large increases in the tax on cigars were necessary to
bring them into line with the tax on cigarettes. However,

the fact that few people in South Africa smoke cigars on
a regular basis, and that they are regarded as luxury and

health promotion strategies. However, the lobby groups

were unsuccessful with these requests, even after the

changes of the 1990s were implemented. As a rule, the

South African government does not earmark revenues.4 It
is argued that earmarking distorts the prioritization of gov­
ernment policies, and could lead to economic inefficiency

in the spending of these funds.
The MRC and NCAS regularly pointed out that the real

excise tax rate had been decreasing during the 1970s and,
even faster, during the 1980s. Even though this point

was well taken in the Department of Health, the Ministry

of Finance did not increase the tax. The government
explained its inaction as follows: (1) increasing the tax

would stimulate smuggling, and (2) an increase in the tax
might, in fact, decrease government revenue, because the

"special events" items, suggests that the primary aim of
increasing the tax on cigars was to increase government

revenue.

4

Exceptions to the rule are the Unemployment Insurance
Fund, the Skills Levy, and levies to fund regulatory bodies
of specific industries

6

Tobacco Excise Taxation in South Africa

tax-induced price increase would cause a sharp reduction

the Minister of Finance increased the tax by only 25 per

in demand. In providing these explanations, the Ministry

cent in 1994. Although this was a temporary setback for

of Finance apparently did not question their empirical

the health community, the tax was increased by substan­

foundations; they were generally taken as an article of

tially greater percentages in subsequent years. The guiding

faith from the tobacco industry.

principle for each of the subsequent tax increases was the

In the early 1990s, after the ban on the ANC had been
rescinded,5 and negotiations for a democratic transition

"50 per cent goal" announced in 1994.
The industry was naturally furious about the excise tax

were taking place, the tobacco control groups started

increases. The Tobacco Institute of South Africa was par­

lobbying the ANC for stricter tobacco control measures,

ticularly vocal about the "discriminatory" tax increases.

including rapid tax increases.6 The tobacco control lobby­

They argued that tobacco was already the most highly

ists found an ally in Dr Nkozasana Zuma, the later Minister

taxed consumer product, and that such large tax increases

of Health. She was passionately against smoking and, in

would encourage smuggling. Furthermore, they argued

this regard, had the full support of the president-to-be,

that the tax would decrease tobacco consumption, which

Nelson Mandela.

would cause large numbers of workers to be retrenched.

In June 1994, less than two months after the democratic

The chairman of the Rembrandt Group, the country's

transition, the Minister of Finance announced that the

largest cigarette manufacturer, wrote an open letter to

government would increase the tax on tobacco products

the Minister of Health in 1996 in which he argued that

to 50 per cent of the retail price. The Ministry of Health

smuggling was out of control, and that the government

and tobacco control lobby groups had been lobbying the

was losing revenue as a result. He quoted the example of

Ministry of Finance for a doubling of the excise tax that

Canada where smuggling had reached epidemic propor­

year. Because of pressure exerted by the tobacco industry,

tions, which was reduced significantly after the taxes were

reduced.7
5 The African National Congress is a political party which

In 1996 the tobacco control lobby was strengthened when

was founded in 1912. It was banned for 30 years under

the Economics of Tobacco Control (ETC) Project was

the apartheid regime, from 1960 to 1990.

established at the University of Cape Town. Among other

6 It must be noted that the National Party government

passed the country's first tobacco control legislation in
1993. This was the result of persistent lobbying with the

then Minister of Health. The legislation was mild, even by
1993 standards, but it nevertheless represented a schism

between the NP government and the tobacco indus­
try. This legislation did not make any provisions for tax
increases. However, the more comprehensive legislation of

1999 did not include such provisions either.
7 However, subsequently it was found that the tobacco

things, the Project quantified how much revenue the gov­
ernment had lost during the 1970s and 1980s by allow­

ing the real excise tax to fall so sharply. This effectively
destroyed the industry's argument that the government

might lose revenue by increasing the tax, because of the

reduction in consumption that it would cause. The tobacco
control lobby used these and other research results of the
ETC Project to counter the industry’s claims that tobacco

benefits the economy as a whole.8

The tobacco control lobby was heavily dependent on infor­

industry was involved in the smuggling network. Litigation

mation and news in order to retain the attention of the

is currently being brought against Brown & Williamson

public and the policymakers. Research results and tobacco

regarding their role in the smuggling.

related news from developed countries certainly maintained

public awareness, but locally produced research results
8 The ETC Project was not the first to investigate the eco­

generally received more media attention. The tobacco con­

nomic impact of smoking, but it was the most compre­

trol lobby in South Africa used locally generated research

hensive. So, for example, a cost benefit analysis performed

outputs to influence policymakers. This is important

by the University of Cape Town’s Health Economics Unit

because policymakers want to know what the impact of

in 1988 Indicated that, for every R1 received in tobacco

certain interventions is likely to be on the South African

taxes, the economy incurred medical costs and lost pro­

situation. They are generally not very interested in, or per­

ductivity of R4.

suaded by, research that has been performed in a different
country, possibly under very different circumstances.

7

World Health Organization

The public’s reaction to the tax increases has been mixed.

ship between these two variables. The increase in excise

In the "letters" section of newspapers people have

taxes explains about half of the real price increase since

expressed both support for and disappointment in the tax

1991; the other half is attributed to the industry's pricing

increases. Surveys indicate that most people, mainly non-

strategy (discussed in section 5). Since 1991 total cigarette

smokers, but also a sizeable proportion of smokers, gener­

consumption has decreased by a third; in per capita terms

ally support strategies aimed at reducing smoking.

it has decreased by more than 40 per cent.

Success of the Intervention

It was found that approximately 40 per cent of the

decrease in cigarette consumption was to be ascribed to
Internationally, tobacco control advocates generally

people giving up smoking. This is reflected in the fact

propose a comprehensive strategy in the fight against

that the smoking prevalence percentage among adults

tobacco. Such a strategy would typically consist of an

decreased from 33 per cent in the early 1990s to 27 per

advertising ban, clean indoor air policies, restrictions on

cent in 2001. The other 60 per cent of the decrease in cig­

sales to minors, an effective education programme, and

arette consumption is explained by the fact that smokers

tax increases. The international literature indicates that, of

are smoking less. In fact, average cigarette consumption

all these interventions, increases in tobacco taxes are the

per smoker has decreased by approximately 20 per cent in

most effective in reducing tobacco use.

the past decade.

The South African experience confirms these findings.

An analysis of smoking prevalence in South Africa reveals

Econometric studies have shown that the average price

that young people, low-income earners, black South

elasticity of cigarettes in South Africa is between 0.5

Africans and males have experienced the largest reductions

and 0.7. This means that, all other factors (e.g. income)

in cigarette smoking. Smoking prevalence among young

remaining constant, the consumption of cigarettes

people decreased from 23 per cent in 1993 to 19 per cent

decreases by between 5 and 7 per cent for every 10 per

in 2000; among low-income earners from 31 per cent to

cent increase in the real price of cigarettes.

25 per cent; among black South Africans from 28 per cent
to 23 per cent, and among males from 51 per cent to 44

In Figure 1 the relationship between cigarette consumption

per cent. Surprisingly, smoking prevalence among black

and the real price of cigarettes is shown for the past four

South Africans has decreased despite a heavy tobacco

decades. The figure clearly illustrates the inverse relation­

advertising campaign, specifically focused on emerging

Figure 1

Consumption of cigarettes (millions of packs)

Cigarette consumption and real prices of cigarettes in South Africa, 1961 to 2001

Tobacco Excise Taxation in South Africa

middle-class black South Africans in the second half of

rich. This means that, while the absolute burden of the

the 1990s. The demographic groups that have not experi­

tax is likely to increase for all income groups, the burden

enced significant decreases in smoking prevalence include

on the poor, relative to that of the rich, is reduced. Thus,

females (although, admittedly, their smoking prevalence

even though excise taxes are regressive, increases in excise

level, at 13 per cent, is relatively low), high-income earners

tax reduce the regressivity of excise tax.

(32 per cent), and white South Africans (36 per cent).
Studies performed in other countries indicate that young

Other Effects of the Intervention

people and the poor are more responsive to cigarette price

While the primary aim of a tobacco control strategy is to

changes than older and more affluent people. The reason

reduce tobacco consumption, an agreeable by-product

is straightforward: an increase in the price of cigarettes

of increasing the excise tax on tobacco is that it increases

makes the product too expensive to those groups, with

government revenue. Column (j) of Table 1 shows that,

the result that they either reduce their consumption or quit

despite a 33 per cent reduction in tobacco consumption

altogether. The evidence from South Africa supports the

over the past decade, real government revenue has more

hypothesis that young people and the poor tend to reduce

than doubled. Since 1994, for every 10 per cent increase

their cigarette consumption by a greater percentage than

in real excise tax, real excise revenues have increased by

other groups in reaction to a price increase.

approximately 6 per cent.

A related issue concerns the regressivity of an excise tax

The tobacco industry has been ferocious in its opposi­

on cigarettes. Some people are against using excise tax

tion to any tobacco control measures, including excise tax

increases as a tobacco control tool because it could have

increases. Under the present government, the policy on

a detrimental impact on the poor. Since the poor, vis-A-vis

tobacco and tobacco control is unlikely to change. The

the rich, generally spend a larger portion of their income

industry has had to drastically change its marketing strat­

on tobacco products, they pay proportionally more tax.

egy under these difficult external conditions.

This implies that the tax is regressive, which is regarded as
socially inequitable.

Whereas the pricing strategy of the cigarette manufac­

turing industry before the 1990s was focused primarily
However, it has been shown that, in South Africa, an

on the growth in cigarette quantities, there is currently a

increase in the tax on cigarettes causes a larger reduction

much stronger focus on the growth in price. Column (i)

in cigarette consumption among the poor than among the

in Table 1 shows that the real industry price (i.e. the retail
price less all taxes) did not change much between the

9

The Department of Customs and Excise has recently com­

missioned a study aimed at quantifying the number of

smuggled cigarettes. However, to the author's knowledge,
the results of this research are not yet known. An analysis

by the Economics of Tobacco Control Project, based on

rather cursory data, suggests that between 5 and 7 per

cent of cigarettes consumed in South Africa are not taxed
by the authorities. This percentage compares well with
most European countries.

10

In a recent newspaper article, BAT claims that 148 mil­

lion cigarettes were confiscated by the Department of
Customs and Excise in 2001. This is about 0.6 per cent

of total cigarette consumption in South Africa. However,
the proportion of smuggled cigarettes impounded by the
authorities is unknown. On the other hand, the smuggling

and trade in hard drugs (especially heroin and cocaine) is a
serious problem in South Africa, and attracts much media

attention.

1960s and the early 1990s. If anything, the real industry
price decreased over this period. However, there has been

a very rapid increase in the real industry price since 1991
and especially since 1996. In 2001 the real industry price

of cigarettes had increased by more than 60 per cent
compared to the early 1990s. An analysis of the industry's

major cost factors indicates that this increase is not the
result of an increase in the real costs of producing ciga­
rettes.

There is only one explanation: the industry is maintain­

ing its overall profitability by increasing the profit per

cigarette, despite the fact that quantities are falling. The

external environment has turned against the industry to
the extent that future growth in cigarette quantities seems
unlikely. Since the merger between Rothmans (of the
Rembrandt Group) and British American Tobacco (BAT)

in 1999, one company has controlled 95 per cent of the

South African cigarette market. This gives the newly cre­
ated BAT the necessary monopoly power to raise cigarette

9

World Health Organization

prices above competitive levels. The industry can disguise

and to undermine tax policies. If smuggling, especially of

the retail price increases behind the well-publicised tax

Marlboro, into South Africa becomes uncontrolled, this

increases.

could enable Philip Morris to formally enter the market.

A simulation analysis has indicated that this strategy has
been very beneficial to the cigarette manufacturing indus­
try. The strategy has increased total sales revenue for the

For this reason it is in the interest of the dominant incum­
bent (first Rembrandt, and now BAT) to contain smug­
gling.

industry, with the result that the profitability of the indus­

Apart from keeping Philip Morris out, the industry has

try has been enhanced. Also, the strategy has reduced the

obvious motives for emphasizing the smuggling problem

government's ability to increase its excise tax revenue. By

in South Africa. If cigarettes were smuggled on a large

increasing the real industry price the industry siphoned off

scale, the logical step, according to the industry, would

the extra revenue to itself, at the expense of the govern­

be to reduce the tax on cigarettes. This is exactly what

ment. The downside, from the industry's perspective, is

happened in Canada in the early 1990s.11 While some

that its pricing strategy has further reduced cigarette con­

informal bootlegging and some more organized smuggling

sumption. The actions of the industry suggest that they

definitely occur, cigarette smuggling is not a serious threat

are in an end-game scenario, looking to milk the cow for

to the government’s excise tax policy.

all it is worth before it finally dies.
From a tobacco control perspective the industry's pric­

Conclusion

ing strategy has been beneficial, because it has reduced

South Africa has been able to significantly reduce its

cigarette consumption by a much greater percentage than

tobacco consumption in a decade. While strong tobacco

what the excise increases would have achieved in isolation.

control legislation and changing social norms have created

It is ironic that the industry itself, in its attempt to further

an environment where smoking is increasingly regarded

its own short-term interests, followed a strategy that ben­

as socially unacceptable, the instrument with the biggest

efited both the industry and the tobacco control lobby.

impact has been excise taxation.

An issue of considerable importance in many countries

In South Africa, as in most countries, it is administra­

is that of cigarette smuggling. In South Africa, when­

tively easy to change the excise tax on tobacco. What is

ever the excise tax on tobacco products is increased, the

required is the political will to challenge the vested inter­

industry claims that this will increase smuggling activities.

ests of the tobacco industry. In South Africa the Minister

Unfortunately, given the dishonest character of cigarette

of Health and nongovernmental organizations played a

smuggling, accurate data do not exist.9 Over the past

pivotal role in implementing a comprehensive tobacco

decade there have been very few reports of smuggled

control strategy, of which large increases in the excise tax

or counterfeit cigarettes being impounded by the South

are a key part.

African police or customs authorities.10 While this is not

meant to imply that cigarette smuggling is not a problem,

it can be said with confidence that South Africa does not

experience the cigarette smuggling problems currently

experienced by the UK and, in previous years, by Canada.
Also, considering the official consumption statistics (as

shown in column (b) of Table 1), the decrease in cigarette

The effects of an increase in the excise tax on cigarettes
are soon felt: cigarette consumption decreases and gov­

ernment revenue increases. In South Africa the impact
of the excise tax increases was enhanced by the industry
when it increased the real retail price by more than the

increase in the real excise tax.

consumption in the past decade seems reasonable in view

An important proviso concerns cigarette smuggling. While

of the very sharp increase in the real price of cigarettes.

South Africa's experience can, in principle, be easily dupli­
cated in other countries, the success of such a strategy

An interesting characteristic of the South African cigarette

will depend crucially on whether the country can contain

market is the absence of the Marlboro brand. In fact,
Philip Morris has no presence in South Africa. In a court

case in 1998 Rembrandt accused Philip Morris of smug­

10

11

However, the logic is flawed. Evidence from several coun­

gling cigarettes into South Africa via neighbouring coun­

tries shows that tax reductions do not, in themselves,

tries. Tobacco industry documents clearly reveal that ciga-

reduce smuggling.

rette smuggling is used to gain market entry and/or share

Tobacco Excise Taxation in South Africa

cigarette smuggling within reasonable limits. In South
Africa cigarette smuggling certainly did not undermine
the strategy, despite the industry's claims to the contrary.

Although individual countries may differ, international
experience shows that, despite smuggling, higher tobacco
tax decreases tobacco consumption and increases govern­
ment revenue. Smuggling erodes but does not completely

destroy the benefits of higher taxes.
Regarding cigarette smuggling, the industry has its own

reasons for exaggerating the threat. In countries where
smuggling could be a problem, the authorities should
impose strong control mechanisms, including stiff penalties,
cooperative efforts with customs and law enforcement offi­

cials in other countries, and laws to make exporters respon­
sible for their exports all the way to a final legal and taxed

destination, thus discouraging potential smugglers.

11

Tools for Advancing Tobacco Control
in XXIst century:

Success stories and lessons learned

Outils pour poursuivre la lutte antitabac
au XXPsiecle:

Experiences concluantes
et nouveaux enseignements

Advertising and
Promotion
Bans

Norway: Ban on Advertising and Promotion

WHO/NMH/TFI/FTC/03.2

pH-/S

Tobacco Free Initiative would like to thank
the Centers for Disease Control and Prevention (CDC), Atlanta, USA

for their generous support for this project.

© World Health Organization 2003

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Printed in World Health Organization, Geneva.

Norway: Ban on Advertising

and Promotion
Kjell Bjartveit
Former Director of the National Health

Screening Services, Norway
Former Chair of the National Council
on Tobacco and Health, Norway

World Health Organization

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

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Norway: Ban on Advertising and Promotion

Background

Figure 1

Introduction

Total sales of tobacco advertisements by Norwegian
advertising agencies, 1959-75

0

Norway constitutes the western part of the Scandinavian

peninsula with a population of 4.5 million. The country
does not grow tobacco, but has a tobacco industry with a

long tradition.
The standard of living is high; unemployment is low rep­

resenting, in April-June 2002, about 4.0% of the labour
force. Price levels and wages are relatively high.
The population's health is fairly good, with life expectancy

figures being one of the highest in the world. The health

service and social security system are well developed.
A democratic form of government and a separate judicial
system ensure everyone freedom of expression, the right
to vote, and protection under law. The welfare state is

Source: A/S Norsk Reklamestatistik

based on ideals of equality and justice, which are clearly

stated in its legislation: everyone has the right to employ­

The tobacco-advertising ban was enforced on 1st July

ment, an education, social security and health service.

1975; the obvious reason for the low 1975 figure. The

Tobacco advertising in Norway

of the industry's marketing activities as the time for ban

relatively low figure for 1974 may be due to a slowing down

Before World War II, Norwegian broadcasting ran pro­

grammes with radio advertisements that included tobacco.

After the war, radio advertisements for all products were

enforcement approached; it is not explained by a general

lowered advertising activity, cf."Counter attack".

The extent of tobacco promotion in Norway measured

abolished and were not allowed again until the 1990s; the

by expenditures was moderate, however, compared with,

same applied to TV advertisements. Tobacco advertising,

for example, the United Kingdom and the United States

however, was prohibited (see later).

of America (2). For 1974, expenditures per inhabitant on

Tobacco advertisements began appearing in Norwegian

print media in the latter half of the 19th century, first in

newspapers and magazines.

newspaper and magazine advertisements, movies, trade
papers and outdoor posters were the equivalent of USS

0.69 for Norway, USS 1.00 for the United Kingdom and

USS 1.14 for the United States (all figures given in 1974

The degree of tobacco advertising can be measured by

values). It should also be remembered that large sums

expenditures. In the figure below (figure 1), the trend of

were used in the United Kingdom and the United States

advertising activity is presented as annual total sales of

for other promotional activities, which did not exist in

tobacco advertisements by Norwegian advertising agen­

cies, 1959 to 1975. Sales are given in Norwegian crowns
(NOK) for 1979 prices, VAT not included1. During the
entire period, the sales tripled. From 1960 to 1970 sales
increased by 125% for all media. For magazines, however,

the increase was 600% (1).

Norway (gift coupons, sport sponsorship, etc.).
The amount of advertising in printed media can also be

measured by area. The total quantity per year of tobacco
advertising in two popular weekly family magazines, each

with a circulation of more than 300000 copies per week,

was presented in a paper published recently; (see figure 2)
(3). As magazines attract female readers in particular, it is

interesting to note that the total area of tobacco advertise­

ment increased 12 times in the ten-year period from 1964

1 In 2003, 1 US$ = NOK 6.85

3

World Health Organization

Figure 2

In January 1964, the Director General of Health Services

Area (dm2) of tobacco advertisements published in two
Norwegian magazines, 1955-75

(5), i.e. in the same months as the United States

released a report on "Cigarette Smoking and Health"
Surgeon General’s Committee issued its famous report

"Smoking and Health”. Both reports were covered in the
Norwegian press.

The Committee for research in smoking
habits
Appointment of the committee
As early as February 1964, shortly after the release of the
reports by the American and Norwegian health authori­

ties (cf. "Early recognition of the tobacco and health

problems”), the tobacco control issue was thoroughly
debated in the Norwegian Parliament. A unanimous reso­

lution was passed in which it was stated that:
... the Pariiament requests the Government to set

to 1973; an increase much higher than for the total extent

of tobacco advertising (figureD. The share featuring
women in the advertisements in the two magazines went
up from 33% between 1955 and 1964 to 62% between

up a broadly based committee whose main task

should be to plan the campaigns against harmful
cigarette smoking.

In February 1965, at the initiative of the Director-General

1965 and 1975, when 51 % of the advertisements showed

of Health Services, such a committee was set up (the Chair

women smoking, against 31% men. Pre-1964 advertise­

was the chief physician Kjell Bjartveit). The interdisciplinary

ments primarily contained information to smokers on

Committee was given the following terms of reference:

price, type of tobacco, packaging and country of origin;

after 1964 the advertisements developed a more universal
appeal, associating smoking with various social situations
marked by style, well being and comfort. It is obvious that

the industry’s advertising activities focused increasingly on
a female market.

Early recognition of the tobacco
and health problem

In Norway, nongovernmental organizations (NGOs) play a
vital role as pioneers of tobacco control. In the late 1950s,

... to submit a report, based on a comprehensive

scientific analysis, on what measures can be imple­

mented to counteract the adoption of smoking
habits and to encourage the discontinuance of

smoking or reduction of tobacco consumption.

The Committee’s report

In September 1967, the Committee’s unanimous report
of 245 pages, “Influencing Smoking Behaviour", was

released (6).2

the Norwegian Cancer Society started disseminating infor­

The Committee recommended that tobacco control strat­

mation on the harmful effects of tobacco in the schools,

egy should be based on a combination of information,

and a small but active group, the Norwegian Tobacco and

restrictive measures and cessation activities. Lack of bal-

Health Association, started to lobby for an advertising ban,

by sending its periodical to the parliamentarians and by
visiting key politicians and lobbying for a ban.
At an early stage, prominent medical authorities became

concerned with the health consequences of tobacco.

Among them was the prominent pathologist Professor Leiv
Kreyberg, who published several papers on smoking and

4

lung cancer (4).

2 In 1969, the International Union Against Cancer (UICC)
published a shortened English version of the report, cf. ref.

no 6.

3 In 1971, the National Council on Tobacco and Health was
established by Royal Decree.

Norway: Ban on Advertising and Promotion

ance between these three components would decrease the

tobacco products is a clear signal of the seriousness with

effectiveness of such a triple programme.

which the authorities regard the situation.

The restrictive measures included a total ban on tobacco

The Committee's opinion is that the total effect of a prohi­

advertising, compulsory health warning on packages, an

bition against advertising would be:

active price policy, maximum levels of emissions of spe­

— A possible direct and immediate effect on the devel­

cific harmful substances, restrictions on smoking in public

opment of total consumption, essentially by slowing

transportation and indoor public spaces, and prohibition of
sales to minors.

down an expected increase.
— An effect beyond this through changes in attitudes of

The Committee recommended that a permanent multidis­

the public resulted from the well-defined position thus

ciplinary council with a secretariat be established to super­

taken by the authorities in the relationship between

vise and coordinate the Government's smoking control

work.3
Since this report concentrates on the advertising ban, it

should be strongly emphasized that this measure is only a

part of the total programme.
The Committee’s report was covered extensively by the
media, which focused almost entirely on the proposal for

an advertising ban.

tobacco smoking and harmful effects. The Committee
is of the opinion that this will have an immediate and

strongly smoking-negative effect. This immediate
effect will decrease over time, but will still be present

in a permanently negative labelling of all attempts of
smoking-positive influence.
— A certain weakening of the competitive situation of

Norwegian manufacturers versus foreign producers.
— A reduction in the advertising income of the press,

estimated to be NOK 6-7 mill per year.

The Committee's motives for

The term used by the Committee, "... restricted as far in

an advertising ban

the direction of a total ban on advertising that is practi­

Although the entire Committee was responsible for its

cally enforceable", was later applied by political bodies

report, the chapter on an ad ban was written by one of

that discussed the subject.

its members, Professor Leif Holbaek-Hanssen, Professor of

Retrospectively, it may be said that the Committee was

Distribution and Marketing Economics at the Norwegian

fairly correct in its predictions of the effect upon consump­

School of Economics and Business Administration, and the

tion (cf. "Effect upon consumption and smoking rates").

country's leading expert in this field. The Committee con­
cluded:

Follow up on the committee's report

... that the volume of tobacco advertising should

be restricted as far as possible in the direction of

The 1969 political party conventions

a total ban of advertising as is practically enforce­

Between 1968 and 1969 political parties were engaged

able. Even if advertising may perhaps not strongly

in drawing up their party's public policy declaration4 to

affect present consumption, it must be considered

be adopted by the party conventions before the General

that the fact that advertising is permitted may,

Election for the Parliamentary period 1969 to 1973 (7). In

on a long-term basis, be interpreted as indicating

Norway, all nominees throughout the country are commit­

that the harmful effects of smoking have not been

ted to their declaration, unless they have publicly reserved

proved. The lack of advertising restrictions implies

the right to their own opinion on a particular issue.

that those authorities that might introduce such
restrictive measures do not use their powers. The

implicit effect could be that the public consciously

or unconsciously believes that smoking cannot be

A party's public policy declaration before an election is a

so dangerous, since "responsible" authorities still

booklet that describes the party's intentions in all sectors

permit tobacco advertising.

of public life during the forthcoming years. It is binding for
the party and its MPs; the party would loose credibility in

In light of the above, the Committee is of the opinion
that the main effect of a prohibition of the advertising of

the electorate if it goes against its own declaration.

5

World Health Organization

Traditionally, public health issues appeal to the electorate;

when there is a threat to health, people demand action.
This may be why four out of the five parties represented
in the Parliament from 1969 to 1973, quite independently
included an advertising ban in their public policy declara­
tion. There is reason to believe that the 1967 report from

the Committee for Research in Smoking Habits, and the
publicity around it, had an influence upon this decision.

milestone. Since 1970 Norway has had an active govern­
ment tobacco control programme.

Specifically, the Parliamentary Committee recommended

working out a draft for an act that would impose as com­
plete a ban on advertising that is possible to enforce in

practice.
The legal drafting committee

Of the five parties, the Conservatives did not include an

In July 1970, the Government appointed a Committee

advertising ban in their public policy declaration; most

to draft the Act proposed by the Parliament (the Chairs:

probably it was never considered. The three medium­

Professor Anders Bratholm and Dr Juris) (8).

sized parties in the centre (the Centre Party, the Christian
Democratic Party and the Liberal Party) did so, which was

The Committee defined advertising as the ‘paid mass com­

not surprising, considering their ideological basis. Of par­

munication of information and ideas with the object of

ticular importance, however, was that the same decision

publishing the available offers and of creating definite

was made at the convention of the Labour Party. Here,

attitudes in the consumers in such a way as to facilitate

the proposal came from the party's women's organiza­

sale'. To start with, the Committee tried to list all forms of

tion, and, in fact, was carried through by one dedicated

advertising that should be included in the ban. However,

woman, Mrs. Merle Sivertsen, in particular.

the Committee found it impossible to produce a list that

would cover the future rapid pace of developments in the
This meant that the MPs of the four parties were commit­

field of mass communication and advertising technique.

ted. Since together they formed a majority on the issue,

Therefore, the Committee found that the purpose was

the battle was, to a large extent, already won. In the

best served by laying down a general principle in the text

author's opinion, those few months prior to the General

of the Act, that the advertising of tobacco products is pro­

Election in 1969, were the most important period in the

hibited. Branding all such activity illegal would give a clear

history of the Norwegian tobacco advertising ban.

signal that all the various stages in the communication­

One may ask where the opponent was, where was the

chain would be compelled to respect.

tobacco industry when the political parties were drafting

The Committee recommended that the Act empower the

their manifestos? At that time the industry remained fairly

Ministry of Health and Social Affairs to grant dispensation

silent on the issue. Perhaps the industry failed to see the

from the fundamental principle in special cases, for exam­

writing on the wall and the upcoming political conven­

ple, if at some future date tobacco products can be pro­

tions. Or perhaps its communication with the international

duced that are not associated with health risks, and in the

industry was inadequate, so that the threat was not appar­

case of particular forms of advertising which, in practice,

ent. It also is possible that Norway was looked upon as a

are difficult or impossible to control.

remote market of minor importance, so that the snowball­
effect on other countries was disregarded. In any case,

the industry's low profile in 1969 is surprising, at least
compared with the international industry's strong attempts
today to present the Norwegian law as a failure. And as
we shall see in section "Counter attack", the Norwegian

industry’s concern changed markedly shortly after 1969.

The general ban was also to cover tobacco products
shown in advertisement of other goods or services.

Although it may be held that, strictly speaking, such cases
are not advertising of tobacco, the Committee thought

that there was no reason to allow this form of advertising.

First, it may have considerable smoking-positive influence,
especially when it combines smoking with the use of typi­

The 1969 White paper

In 1969, the Government included the Committee's report
in a White Paper to the Parliament, and in April 1970, the
newly elected Parliament discussed it. The Parliament's
Standing Committee on Social Affairs endorsed the White

6

Paper unanimously on all main points, thus marking a

cal status symbols. Second, certain tobacco manufacturers
might try to make use of this kind of "sneak-advertising"

to circumvent the general ban of tobacco advertising.

In April 1971, after nine months' work, the Legal Drafting
Committee presented its recommendations.

Norway: Ban on Advertising and Promotion

No more advertising of tobacco as from 1st July. No more bad examples to follow.
As from 1st July there will be no more advertising of tobacco in Norway ...

The Parliament's view is as follows: It hopes that the ban on the advertising of tobacco will imply that fewer young people than at
present will start smoking. It is also hoped that more people than at present who smoke will stop doing so, or will reduce their con­
sumption.

Tobacco smoking endangers health - no doubt about it. This has been established by research. Nobody believes that a ban on adver­
tising will solve the problem. But it may perhaps contribute to a change in our smoking habits. Efforts to inform the public about

smoking will be initiated at the same time as spreading information about the new Act.
We believe that all these elements combined will contribute towards improvement of our smoking habits, and thus to avoidance of

serious disease. And that is the whole point.

The proceedings in Parliament

than the Bill. The majority, the other four parties, support­
ed the Bill, and even strengthened it. On 9 March 1973

In June 1972, the Bill on the Tobacco Act was introduced
by the Government, after gathering comments and opin­

the Act was sanctioned by the Royal Assent of the King in

Council (9).

ions from all bodies concerned. To all intents and purposes

the Bill was in accordance with the draft prepared by the

Legal Drafting Committee.

In 1973, the Bill was debated in Parliament, which now
was divided. The minority, the Conservative members,
presented alternative proposals, which were much weaker

The two first sections of the Act adopted in 1973 read as
follows:

— Section 1: The object of the Act is to limit the damage

to health caused by the use of tobacco.

World Health Organization

— Section 2: Advertising of tobacco products is prohib­

Procedure in cases of infringements

ited. Cigarette paper, cigarette rollers and pipes are

of the Act - the 1970s and 1980s

regarded as tobacco products.
— Tobacco products must not be included in the adver­

tising of other goods and services.
— The King may issue regulations concerning exceptions

to the first and second paragraph.
Enforcement of the Act

In October 1974, the Ministry of Health and Social Affairs
laid down regulations concerning the implementation of

the Act, and on 1 July 1975, the Act entered into force.
Outdoor advertising signs had to be removed before 1
January 1976.

In general, the introductory phase went smoothly. The
tobacco industry and retailers were mainly loyal to the
Act. Nevertheless, some attempts were made to exploit

uncertainty, to balance on the edge of the law or actually
break it.

Staff members of the Ministry and the Council kept an
eye on possible infringements in newspapers and other

printed material. Also, people's reaction to such attempts

occurred quickly. The health authorities were informed
immediately about clear violations of the Act and about
borderline cases open to doubt. Most obvious was a case
where a traditional cigarette advertisement was printed by

The regulations defined 'tobacco products ’ to include

pure accident in a small magazine. Telephones began ring­

cigarettes, cigars, smoking tobacco, chewing tobacco,

ing - from the general public and the mass media.

snuff, cigarette paper, cigarette rollers and pipes. The term
'advertising' should be understood to include mass media

advertising for market promotion purposes, hereunder pic­
torial representation, advertising signs and similar devices,

exhibitions and the like, as well as the distribution to con­

sumers of printed matter and samples etc. The regulations
specifically pointed out the following forms of mass media
advertising 'as known today’: Ordinary written material in

print, radio and television, film, outdoor advertising, spe­

cial printed matter and samples, entertainment and gather­

ings (for example in connection with public performances
and concerts), retail outlets and objects (for example, the

use of named tobacco brands, pictorial representation and
the like on objects such as playing cards, match-boxes,

ashtrays, cloakroom tickets etc. intended for public use)
(9).
The Act was strongly supported by the public. In 1973 a

survey of the population aged 16 to 74 showed that 81 %

In cases of reported infringements, or doubtful incidents,
the following practice was established by the National

Council on Tobacco and Health: All cases were sent to one

of the Council’s legal members, whose professional repu­
tation has been of the highest standard. Their evaluations
were discussed by the Council, and then forwarded to the

Directorate of Health for final decision. With rare excep­
tions, the Directorate agreed with the conclusions of the

legal members and the Council. In cases of infringement,
the Directorate approached the persons responsible. Its

warnings carried various degrees of seriousness; the most
significant being that a new offence would be reported to
the police.

With very few exceptions in the 1970s and 1980s, this

procedure was enough to stop further violation in the par­

ticular case
Professor Asbjorn Kjanstad, Dr Juris, one of the Council's

were in favour of the ad ban and the compulsory health

legal members, and previous Dean of the Faculty of Law

labelling (2).

at the University of Oslo, published a review of the cases

he evaluated during the first eight years, when an average
Nonetheless, the Government found it necessary to intro­

duce the Act to the public through large advertisements

in all Norwegian newspapers and in selected magazines,

of one case a month was dealt with in the way described
(10). His conclusion is:

picturing, for example, a small boy in cowboy outfit, star­

So far the Tobacco Act and those who enforced

ing admiringly at a giant photo of his cowboy hero, a John

it have been victorious as regards the industry's

Wayne-like figure with a cigarette in his mouth, see figure
above. The text in English of the advertisements is given

advertising drive.

And he gives three explanations for his view:

in the frame. It shows that the authorities' expectations as

to the effects of the ban were realistic and modest. And
8

... First, there is a total ban on tobacco advertising

again, it was emphasized that the ad ban was only one

in Norway, and it is therefore virtually impossible

part of a comprehensive programme.

for the industry to find any loopholes in the law.

Norway: Ban on Advertising and Promotion

Second, most of the dubious issues have

against a small minority was passed by the Pariiament. The

been thoroughly discussed in pre-legislative works.

amendments went into force on 1 January 1996. Among

Problems arising in connection with enforcement

other things, the word “all" was added in the first sen­

can nearly always be solved by referring to pre-leg­

tence of this section of the Act, in order to make it clear

islative work.
Third, Norwegian opinion and the National

Council on Tobacco and Health have been keep­
ing a watchful eye on the marketing practice of

that the ban on tobacco advertising was a total one. An

additional provision pertaining to indirect advertising was
also included. The Act now explicitly forbids this kind of
indirect advertising.

the tobacco industry. The authorities have cracked

The wording of the Act’s Section 2, cf. "The proceedings

down on illegal advertising, thus preventing slip-ups.

in Parliament”, is now as follows:

All forms of advertising of tobacco products are
Procedure in cases of infringements

prohibited. The same applies to pipes, cigarette

of the Act - recent years

paper and cigarette rollers.

The tobacco industry, however, did not give in.

Tobacco products must not be included in the

Confronted with the decline in sales since the Act took

advertising of other goods or services.

effect in 1975, (cf. "Effect upon consumption and smok­

ing rates), the tobacco industry tried to circumvent the

A brand name or trademark that is mainly familiar as a

ban in a variety of ways. Great inventiveness was shown

brand or mark for tobacco products may not be used in

in order to bypass the ban.

the advertising of other goods or services so long as the

In this context it is noteworthy that the tobacco industry’s

tobacco product.

name or mark in question is used in connection with a
new attitude occurred at a time when the industry organ­
ized a world symposium in Amsterdam in May 1986. One

Tobacco products may not be launched with the aid of

of the mam themes of this symposium was “Successful

brand names or trade marks which are familiar as, or used

Marketing in a Colder Climate", and the programme pre­

as, brands or marks for other goods or services.

view said:

All forms of free distribution of tobacco products are pro­

Discussions will centre on different ways of com­

hibited.

bating anti-smoking groups and will include pres­

The King may issue regulations concerning exceptions to

entations on successful marketing strategies in

the provisions in this section.

countries where severe restrictions operate.
In order to strengthen the monitoring of the Act, the

In 1992, the National Council on Tobacco or Health

Council employed a full time legal adviser on its staff in

published a report about the increasing use of indirect

the mid 1990s to review, among other things, the cases

advertising. Brand names that were known as a brand for

concerning the advertising ban.5 Most of the cases con­

tobacco products were increasingly used to promote other

cern minor infringements of the law, but the authorities

goods and services. The report outlined the extent of these

still review various campaigns initiated by the tobacco

campaigns, the most widespread being advertising for the

industry. It is estimated that the total number of cases is

clothing brand Marlboro Classics, as well as Camel Boots

approximately 20 per annum. Since 1990 only two cases

and the Barclay Racing Experience. This led to a watering

have been prosecuted by the police; they were, however,

down of the total advertising ban that was intended by

dismissed on the grounds of insufficient evidence, and no

the existing legislation. Unless a very clear ban on indirect

cases have so far been brought to court.

tobacco advertising was adopted, it was feared that in
time, the advertising ban would be undermined.

Therefore, the Council proposed amendments of the Act

that would make the law even clearer on this point. Not

5 Since 2002 the Council's staff has formed a special

surprisingly, the tobacco industry expressed no need for

department for tobacco under the Norwegian Directorate

further amendments. The Government, however, intro­

for Health and Social Services.

duced a bill including a new section 2 of the Act, which

9

World Health Organization

In addition, the Government has found it instrumental to

the parliamentarians’ decision was taken on one or more

introduce another enforcement of the Act, stating that

of the following grounds (11).

those who break the law will be liable to pay enforcement

— a common sense judgement that the extensive,

damages to the authorities. In 2002, a Bill on this amend­

increasing, suggestive and technically advanced adver­

ment was introduced to the Parliament, which is expected

tisements undoubtedly did have a substantial effect

to be debated in 2003.

on young people in particular, recruiting them as new
smokers;

The Parliamentarians' motives
in 1973
Why did the Norwegian parliamentarians jump in with

— a recognition that to support massive campaigns
against a dangerous product, and at the same time
allow massive sales promotion campaigns for the same

these restrictive measures? What were their motives and

product could be looked upon as a double standard,

arguments?

an accusation that would be made by young people in
particular;

It is noteworthy that the politicians reached their

decision without any advance proof of an effect
of an advertising ban. And yet the MPs still voted

for it.

— a desire to give a clear signal of the problem's sever­
ity, and thereby strengthen the effect of campaign

work. On the other hand, if they did not put an end to

tobacco advertising, this could be interpreted as a sig­

Most probably they accepted the reasoning for an ad

nal that there is still some doubt about the danger, and

ban that had been given by the Committee for Research

this would weaken the effect of information campaign;

in Smoking Habits (cf. "The Committee’s motives for an

— the realization that the tobacco industry's voluntary

advertising ban”). In addition, they noted that the Act was

rules had not led to arresting the alarming increase in

supported by the health authorities and health institutions,

tobacco consumption, and that voluntary agreements

and by the nongovernmental health organizations.

would be regarded as compromises and half-measures

In the debate in Parliament, the Minister of Health and

without the clear signal effect that would be achieved

Social Affairs, Mrs. Bergfrid Fjose, stressed that a conflict

exists between the health authorities and those who pro­

by legislative ban;

— and maybe in addition to the arguments above: a

duce and sell tobacco. If less tobacco is used, the result

pragmatic view that important values would not be

will be less tobacco produced and sold. In this matter the

lost by a ban and could by no means outweigh the

authorities responsible for health have to announce clearly
on what side it stands. The opposition's leading spokes­

woman, Mrs. Sonja Ludvigsen, emphasized that voluntary
arrangements would not provide for effective limitation

of the advertising efforts. She had hoped that that the
tobacco industry, for humanitarian reasons, at least, would

value of positive health effects.

In other words: the ban was considered a matter of ethics.
When dealing with an epidemic of such enormous dimen­

sions, it would have been unethical to permit sales pro­

motion for these deadly products to continue regardless of
whether the ban would prove to have a substantial effect.

refrain loyally from contributing actively to increased

consumption. But, on the contrary, the industry had met
every information effort and every report with increased
and expanded advertising, aimed particularly at young

people, most of all at young girls, whom the industry saw

as an unexploited market.6
The author of this report followed the procedure in the

Parliament closely, and was left with the impression that

The counter-attacks
Resistance to the advertising ban came from organiza­
tions in the tobacco trade and in the advertising sector,
and from parts of the press. In particular, the tobacco

industry appeared strongly in the arena and gave com­

prehensive statements to the reports from the Committee

for Research in Smoking Habits and the Legal Drafting
Committee, where they argued vigorously against the ban.
6 Chapter "Tobacco advertising in Norway" (author’s
remark).

In this work, the Norwegian tobacco industry established
close contact with the international tobacco industry. This

has been revealed in the so-called "Tobacco Documents"

Norway: Ban on Advertising and Promotion

that includes letters from the Norwegian tobacco industry
(J.L. Tiedemanns Tobaksfabrik) to The Tobacco Institute in

0

graphs or tables which substantiate the conclusions) (1,

11. 13).

Washington D.C. (12):

The opponents claimed that an ad ban would:

Letter of 15 January 1973:

1.

weaken the competitive situation of the
Norwegian advertising industry

We have tried to make a last-minute effort to

moderate or postpone the law, but under the

Subsequent experience:

present political circumstances this is very difficult.

There has been a continuous increase in the annual

With a Prime Minister and the Minister for Social

turnover of the advertising agencies, and in the two

affairs from the Christian Democratic Party the

eight-year periods before and after introduction of the

anti-tobacco forces would unfortunately have a

ban, the average increase was 3.6% before, and 4.3%

very strong backing in the Government

after; it means a higher increase after the ban.

Letter of 28 February 1973:

2.

weaken the competitive situation of Norwegian
manufacturers versus foreign producers.

For your information, a Tobacco Advertising Ban

Subsequent experience:

has again been discussed by the Nordic Council. A

The cigarettes most commonly smoked in Norway

working group will be set up with the purpose of

are hand rolled. Before the ban, Norwegian brands

establishing similar laws in the Nordic countries. An

attempt from our side to postpone a law in Norway

accounted for about 95% of smoking tobacco used

until the Nordic alternative had been discussed got

for hand rolled cigarettes. This fraction has been fairly

unfortunately no response among the politicians.

constant over the years since the ban. The market

share of Norwegian brands of manufactured cigarettes
Letter of 29 August 1973 concerning the

has declined at the same rate throughout the whole

regulations to the Act:

period; it dropped by about two-thirds from 1965 to
75, and by about two-thirds from 1975 to 1985, the

As expected, the present Government has followed

ten-year periods before and after enforcement of the

a very restrictive line in their present draft.
The Tobacco Manufacturers Association of 1901

ban.
3.

has set down a working committee to prepare the

cause reduced employment in Norwegian
industry.

comments which are asked for in the enclosed let­

Subsequent experience;

ter dated August 16th from the Ministry. As you

will see, any remarks should be sent to the Ministry

The number of employees in the tobacco industry

by October 15,h 1973. The writer is a member of

dropped continuously before and after introduction of

this working committee and any comments you

the ban. The mean annual change was about the same

might have will be highly appreciated.

in the two ten-year periods before and after enforce­

Needless to say, the Norwegian tobacco manu­

tion after. There is no evidence that the ban has had

facturers will do their utmost to moderate the

any influence upon the general employment situation

ment, with a 2.7% reduction before and 2.6% reduc­

regulations, but under the present Government this
will be a very difficult task. It is doubtful whether

the Government will survive the Parliament elec­
tions in September, but even with a new labour

in Norway.
4.

worsen the economic situation of the press.
Subsequent experience:

Government we can hardly expect any major

From 1967 to 1975, eight years before the ban, sales

amendments in the regulations".

of advertisements, of all kinds, to Norwegian newspa­

What were the opponents' arguments? The preamble to

the Bill summarizes the counter-arguments, and the main
points are repeated below, together with some comments

on subsequent developments to the specific argument
(this overview has been published previously together with

pers increased annually by a mean of 3.9%, as against
a 5.6%, annual increase in the eight-year period after

enforcement; that is to say a higher increase after the

ban.
11

World Health Organization

5.

preclude the steering of consumption over to

Subsequent experience:

This question is discussed in the next chapter of this

Denmark and Norway differ as regards restrictions

report. In this context, however, it is remarkable to see

on advertising; Denmark has never had a ban. In the

that parts of the industry, at the least, have a more

years following the ban, the average tar content per

nuanced view now upon this problem, which has been

cigarette sold has decreased as rapidly in Norway as in

disclosed in the Minnesota documents (12). On 27

Denmark, and proportions of cigarettes with tar yields

February 1986 a letter was sent from Philip Morris to

up to 15 milligram increased at least as fast in Norway

the chairman of the Norwegian tobacco manufactur­

as in Denmark. Another example: In 1984, one com­

ers’ association (NMA). The letter comments upon a

pany introduced a new cigarette, claiming that tar

draft prepared by the NMA to the Norwegian health

delivery was as low as one milligram. This was report­

authorities:

ed in the press, but there were no advertisements.

In the final sentence of the NMA’s conclusion, we

Nevertheless, within one year the market share of this

suggest that it is misleading to state that the gov­

particular brand increased from 0 to 6%. So, the ad

ernment's ban on advertising in Norway and other

be contradictory to the Constitution's provision
concerning freedom of expression.

Subsequent experience:
A legal expert, Professor Torkel Opsahl, Dr Juris, who
was employed by the tobacco industry to evaluate this

question, concluded in his report:

In the main I must agree with the Legal Drafting
Committee that the protection of the freedom of

expression will not be legally affected by the provisions
which it proposes.

measures introduced by the National Council on
Smoking and Health have had no particular influ­
ence on smoking habits.

Philip Morris maintains that any objective analysis of

research on cigarette consumption is highly complex,
that a number of factors impact consumption and that
it is very difficult to make generalized statements on
the data.

This view may perhaps be based upon a report which
at the end of the 1980s was prepared by a Norwegian

researcher at the University of Oslo, Professor Jon
Hovi. Philip Morris had hired him to carry out an

This conclusion must have come as a disappoint­

econometric study of the effect of the Norwegian

ment to the tobacco industry, and is not referred to

advertising ban. Obviously, Hovi's results differed from

at all in its comments. The Ministry of Justice received

what Philip Morris expected. The report was retained

Professor Opsahl's report and the industry’s statement,

from publicity, and the researcher was bound to secre­

and said that the Ministry

cy. Nevertheless, Philip Morris sent a statistician from

... agrees with the conclusion reached by Professor

abroad to see Professor Hovi, and this statistician put

Opsahl, namely that the proposal cannot be assumed

forward some suggestions concerning methods and

to violate the Constitution's protection of the freedom

control variables. Hovi's results, however, remained the

of expression.
After enforcement of the ban, the legal opinion of
Professor Opsahl and the Ministry of Justice has been
generally accepted in Norway.
7.

little effect upon total consumption of
tobacco.

ban has not obstructed a shift to low tar cigarettes.
6.

8.

less hazardous products.

be extremely difficult to implement and would

same (14, 15).

Effect upon consumption and smoking
rates
This question has been discussed in details in a special

lead to extensive problems for the prosecuting

report (1), that is also available on Internet7. Some of

authorities in their enforcement of the Act.

the essential points will be summarized below. Problems

It suffices to refer to the section: "Procedure in cases

of infringements of the Act” above, which shows that

in measuring the effect of an advertising ban have been
taken up elsewhere(74, 16).

implementation of the Act, in general, went smoothly.

New problems have been dealt with appropriately in
12

order to fulfil the aims of the Act.

r See: www.kreft.no.

Norway: Ban on Advertising and Promotion

Per capita consumption of tobacco
The figure below shows registered sales of manufactured

cigarettes plus smoking tobacco per adult aged 15 and

Figure 3
Registered annual sales of cigarettes + smoking tobacco
per adult 15+, Norway. Five year means
1950/'51-1999/2000 + mean 2000/'01-'01/'02

above. Sales per capita rose considerably during the 1950s
2100

and 1960s, and reached a peak in the mid-1970s. Since

then they have dropped, and are now below the 1950

2000

figures. The actual peak year was 1975, the year when the

1900

Act was enforced.

1800

When interpreting the Norwegian sales figures, one must

8

take into account the widespread habit in Norway of "roll-

o 1600

your-owns", which come out much cheaper than manu­

° 1500

factured cigarettes. In 1975, when the advertising ban was

2

1700

1400

introduced, about two-thirds of all cigarettes smoked in

Norway were hand rolled. Since then, however, the frac­

1300

tion of hand-rolled cigarettes has decreased substantially,

1200

probably due to the population's greater prosperity.

1100

In order to gain a true picture of the Norwegian scene,

1000

one has to calculate Norwegian sales figures in grams,

assuming the weight of one manufactured cigarette to

Source: Directorate of Customs and Excise, Norway

be 1 gram (which results, however, in an overestimate of
the total consumption for recent years, since the weight

of one manufactured cigarette has decreased from about
1 gram in 1975 to about 0.75 gram from the mid-1980s

onwards) (1). This gives the following picture of sales

trends, calculated as registered sales of grams of tobacco
per adult 15+:

Figure 4
Per cent daily smokers age 13-15, by sex, Norway. Nationwide
surveys 1957, 1963 and every fifth year 1975-2000

This positive development may be expected to accelerate
in the future, when a lower consumption in the younger

generations (see figure 4) will have an increasing impact
on total consumption.

Today, lung cancer mortality in Norway is only half that
already experienced in countries with a history of longer
and heavier smoking like the United Kingdom and Canada

(2, 13). Given the new trend of consumption in Norway
since 1975, the country will never reach these countries'
high level of mortality. An essential health benefit has

been achieved already. As a matter of fact, lung cancer
mortality in males culminated between 1985-1990 (17).
Source: Norwegian Cancer Society/
National Council on Tobacco and Health

13

Smoking rates in young people

than 150000 students), a representative sample has been
drawn and sent to the Council for statistical analysis (1).

There are reasons to believe that young people are more
susceptible to advertising than are adults, hence, an ad

The results from these surveys are presented in the figure

ban is presumed to affect smoking incidence rates in the

above. Two features are striking. First, up to the mid-

younger age groups more than it affects smoking cessa­

1970s, smoking rates rose considerably in both sexes,

tion rates in adults (1). Therefore, it is of interest to com­

particularly among girls, whose smoking rates increased

pare smoking prevalence among persons who grew up in

from 1% in 1957 to 17% in 1975. During these years,

a climate free of advertising with those of persons who

the tobacco industry ran extensive advertising campaigns

went through their adolescence before the ad ban was

aimed especially at a female market, cf. "Tobacco adver­

introduced.

tising in Norway". It may be objected that it is not known

Schoolchildren

that the peak year does not necessarily coincide with the

what happened between 1963 and 1975, and therefore,

As early as 1957, the Norwegian Cancer Society con­
ducted a nation-wide study of smoking habits among
Norwegian school children in the upper grades of compul­

sory school. The study was carried out in a representative

sample of Norwegian schools. The Cancer Society repeat­
ed the study in 1963 (1).

From 1975 onwards, the National Council on Tobacco
and Health has carried out surveys every fifth year among

all schoolchildren in the upper grades of the compulsory
school throughout the country, with attendance rates

of more than 90%. From this universe (results for more

enforcement of the advertising ban. However, another

series of surveys, carried out annually in the age group 15
to 21 in the cities of Oslo and Bergen, show that the peak
was reached in the mid-1970s (18, 19). The highest per­
centage of daily smokers was found in Oslo in 1974 and

in Bergen in 1975.
The second feature from this figure is that in 1975, the

Tobacco Act was enforced. By 1980, smoking rates among
young people were declining for both sexes, and con­

tinued to do so for 20 years. A small increase in the year
2000 gives reason for concern (cf. "Could the results have
been better?”).

Young adults

Figure 5
Per cent daily smokers age 16-24, by sex, Norway Mean
1973-74 + five year means 1975-1999 + mean 2000-01

This age group may also have been increasingly influenced
by the ad ban.

Since 1973, Statistics Norway has carried out annual sur­
veys of smoking habits in representative samples of the

adult Norwegian population aged 16 to 74.
The figure above shows the percentage of daily smok­
ers by age and sex in young adults aged 16 to 24. As

a whole, in the years following the enforcement of the
advertising ban, there were clear downward trends in both
sexes. Since the late 1980s, however, these trends have

levelled off.
Smoking rates in the total population

In the series of surveys carried out by Statistics Norway,
the figures for the total adult population aged 16 to 74

show, as a whole, a downward trend for men and a fairly
stable trend for women. In 2001 the percentages of daily
smokers were 30.3 for men and 29.3 for women; for the

first time the female rate came under 30%. Mean ciga­
14

Source: Statistics Norway/
National Council on Tobacco and Health

rette consumption in daily smokers was 14.0 per day for

men and 11.2 cigarettes per day for women.

Norway: Ban on Advertising and Promotion

However, crude rates for a total population may disguise

From the late 1990s, however, there developed a marked

important developments in different age groups. Broken

increase in government funding for tobacco control pur­

down by age and sex, smoking rates in males aged 45

poses, and new initiatives have been taken in terms of

to 64 have dropped about 35% since 1973. For females,

health warnings on packages, on smoke-free indoor envi­

only small changes are seen, except in the youngest age

ronments and on cessation. In light of these latest signals

group, 16 to 24 years. In women aged 55 and over the

from the authorities, some of the lost ground may be

trend is upward.

recovered.

When interpreting the data for middle-aged and elderly

women, it is necessary to take into account a marked

cohort effect, as described elsewhere (1, 20, 21). In previ­
ous years, smoking was uncommon in these age groups.

Conclusions
In the author’s view, sooner or later Norway would have
had an advertising ban. That it was achieved so soon, was

After World War II, there was a dramatic increase in

brought about by many sectors, among them people from

smoking among younger women, who maintained their

various professions who, with great skill and drive, took

smoking as they grew older. In the individual female

the cause from one step to the next. NGOs lobbied active­

birth cohorts, however, there is a distinct drop in smoking

ly for the ban. Not the least the 1969 political party con­

prevalence.

ventions played a crucial role. Determined politicians were

willing to put the interests of public health before those
The decrease in smoking - other explanations?

of the tobacco enterprise, although they did not have any

As shown, tobacco consumption and young people's

advance proof of the effect of an ad ban.

smoking rates have decreased considerably since the mid-

As a whole, the implementation of the ban has been

1970s. One may ask what the cause is of this marked

successful, in spite of heavy resistance from the tobacco

break in trends. Something new must have happened

industry. The Government has responded by new steps to

in the 1970s that had not been experienced before. No

counteract the industry’s attempts to circumvent the ban.

data substantiate that this change was due to huge price

increases or to restrictions on smoking in public places and

The industry's arguments were the same as we run into

at work. The only reasonable explanation is that the ad

today in many other countries. Today Norway has 27

ban has played an important role in this new trend (1).

years experience with the Act, and all the pessimistic and
tragic events the opponents of the Act predicted have not

A study employing econometric techniques has suggested

occurred. All difficulties were highly exaggerated. No one

that the Norwegian Act enforced in 1975 brought about

has suffered, no values have been lost, and there has been

a long-term reduction in tobacco consumption of 9% to

no serious recommendation to return to tobacco advertise­

16% (22). It is not possible to quantify exactly how much

ments.

of this reduction can be attributed to the advertising ban
itself, but, in the view of the minor nature of the other

provisions of the Act, the ad ban is likely to have account­
ed for the major part.

A cautious conclusion would also be that the advertising
ban, with the concomitant publicity throughout the leg­

islative process, has had an impact on consumption and

young people's smoking, and in combination with the

Could the results have been better?

The ad ban was intended to be one element of a compre­

continued educational efforts was a causal factor in the

new trend.

hensive package, which should include the full range of

This view is also shared in letters from political authorities

anti-tobacco measures (cf. "The Committee’s report”).

(1). In June 1997 the former Health Minister, Professor

Regrettably, from the mid-1980s this did not turn out as
well as hoped for; and thus, the advantage of the ad ban

Gudmund Hernes, PhD, made the following statement:

...there is no doubt that the Norwegian advertising

was not fully exploited. Price mechanisms were used to

ban has had a clear and substantial influence on

only a minor degree, and the resources for information

total consumption in general, and smoking rates

and education were relatively small. This may explain why

among school children in particular. In my view the

the trends regarding young people’s smoking rates have

reduction brought about by the advertising ban will

been less favourable in recent years than previously.

have a positive and marked impact on the future

15

World Health Organization

incidence of smoking-related diseases, and conse­

1955-75 period? Tidsskr Nor Lxgetoren, 2002; 122: 310-6

quent mortality.

(in Norwegian, summary in English).

In May 1998 the present Health Minister Mr. Dagfinn

4.

HoybrAten stated:

Universitetsforlaget, 1969.

I share the view that the ban on advertising of
tobacco products has had a marked and beneficial

Kreyberg L. Aetiology of lung cancer. A morphologi­

cal, epidemiological and experimental analysis. Oslo:

5.

influence upon tobacco consumption and young

Sigarettroyking og helse.. En redegjorelse fra helsedirektoren.

Tidsskr Nor L&geforen 1964; 84: 300-05 (in Norwegian).

people’s smoking rates in Norway. In my opinion,

however, the effect of legislation could have been

6.

Bjartveit K, Christie N, Holbaek-Hansen L, Mork T. Nilsen E,
Vormeland O, As B Report of the Committee for Research

even better if the ban had been accompanied by a

much more active and offensive use of other smok­

in Smoking Habits, appointed by The Norwegian Cancer

ing control measures, in particular, health informa­

Society. In: Wakefield J, ed. Influencing smoking Behaviour.
Geneva: UICC, Technical Report Series. Volume 3, 1969.

tion and education. Shortly after I took office, I
presented a proposal to increase substantially the

grant for such activities. My intention is to maintain

7.

Bjartveit K. The history of the Norwegian ban on tobacco
advertising. In: Lock S, Reynolds L, Tansey EM, eds. Ashes to

a considerably higher involvement in a comprehen­

ashes: The History of Smoking and Health. Clio Medica 46

sive smoking control programme, including legisla­

in the Wellcome Institute Series in the History of Medicine.

tive measures.

Amsterdam; Editions Rodopi B V, 1998: 216-20.

In 1993 the 3rd International Conference on Preventive

Cardiology was held in Oslo. In an address to Conference,

8.

Recommendation concerning an Act on Restrictive Measures

for the Marketing of Tobacco Products etc (the Tobacco

the Norwegian Prime Minister Dr Gro Harlem Brundtland

Act). By a Committee appointed by Royal Decree of 31 July

brought the advertising ban to a global perspective (23):

1970. Oslo: The Royal Ministry of Social Affairs, 1971.

Most outrageous is the fact that the tobacco indus­

try, to serve its own interests in developing coun­

9.

Tobacco Products etc. (Norway) Oslo: National Council on

encourages the growth of tobacco crops, but at the

Smoking and Health, 1975.

same time advertises a Western lifestyle with ciga­

10.

rettes as the major symbol...

of the Fifth World Conference on Smoking and Health,

tion of tobacco. It should not be too much to ask

Winnipeg, Canada, 1983. Ottawa: Canadian Council on

governments to abolish such marketing activities

Smoking and Health, Canada, 1983: 1:567-73.

altogether.

References
Bjartveit K, Lund KE. The Norwegian ban on advertising of

tobacco products. Has it worked? Oslo: Norwegian Cancer
Society/Norwegian Health Association, 1998 Available on

web site: www.kreft.no.
2.

Bjartveit K. Legislation and political activity. In: Forbes WF,
Frecker RC, Nostbakken D, ed. Proceedings on the 5th World

Conference on Smoking and Health, Winnipeg, Canada

1983. Volume I. Ottawa: Canadian Council on Smoking and
Health: 31-45, 1983.

3.

16

Kjonstad A. The tobacco industry and the ban on advertising.

I: Forbes WF, Frecker RC, Nostbakken D, ed. Proceedings

We can and should put an end to all sales promo­

1.

The Act relating to Restrictive Measures for the Marketing of

tries, is taking on the role of a benefactor which

11

Bjartveit K. Fifteen years of comprehensive legislation: results

and conclusions. In Durston B, Jamrozik K, eds. Tobacco
and Health 1990. The Global War. Proceedings of Seventh

World Conference on Tobacco and Health 1990. Perth:
Health Department of Western Australia, 1990:71-80.

12. Bjartveit K. Minnesota-dokumentene. In: Oppfolging av
NOU 2000:16 Tobakksindustriens erstatningsansvar. Oslo:

Sosial- og helsedirektoratet, avdeling tobakk, 2002 (in
Norwegian; quotes in English).

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Lund KE. What messages did the Norwegian tobacco indus-

Paris: Tobacco Prevention Section, International Union

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Against Tuberculosis and Lung Disease, 1996: 225-45.

Norway: Ban on Advertising and Promotion

14

Lund KE. Tobacco advertising and how to measure its effect

Acknowledgements

on smoking behaviour. In: Slama K, ed. Tobacco and Health.

15.

Proceedings of the Ninth World Conference on Tobacco and

Rita Lindbak and Siri Naesheim, both senior consultant officers

Health 1994. New York: Plenum Press, 1995: 199-204.

with the Norwegian Directorate for Health and Social Services.

Kalve L. Tobakksgigant skjulte norsk forskning. Oslo:

Nettavisen, 10 Ocktober 2000 (in Norwegian. Title: Tobacco
giant hide Norwegian research).

Department for Tobacco Control, have assisted in preparing the

text. Professor Asbjorn Kjanstad, Dr Juris, and Senior Researcher
Kart Erik Lund, PhD, have commented on the manuscript. The

author wishes to thank them for their contributions.

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Bjartveit K. The effect of an advertising ban - who has the

burden of proof? In: Slama K, ed. Tobacco and Health.

Proceedings of the Ninth World Conference on Tobacco and
Health 1994. New York: Plenum Press, 1995: 205-8.

17.

Tverdal Aa. Nelson E. Dodeligheten i Norge av forskjellige

Arsaker. Oslo: Statens helseundersokelser. SHUS-rapport nr.
3/2001. 2001 (in Norwegian).

18.

Irgens-Jensen O, Rud MG. Bruk av staffer, alkohol og

tobakk blant gutter og jenter. Oslo 1968-76. Oslo:

Universitetsforlaget, 1979 (in Norwegian).

19.

Irgens-Jensen O. Bergens-ungdommens bruk av staffer,
alkohol og tobakk 1971-79. Oslo: Statens institutt for alko-

holforskning, 1980 (in Norwegian)

20.

Lund KE. Samfunnsskapte endringer i tobakksbruk i Norge

i det 20. Arhundre. (Social influences on tobacco use in the

20th century Norway). Thesis. Oslo: Departement of soci­

ology and social geography, University of Oslo, 1996 (in
Norwegian).

21.

Ranneberg A, Lund KE, Hafstad A. Lifetime smoking habits

among Norwegian men and women born between 1890 and
1974. Int J Epidemiol 1994; 23: 267-76.

22.

Effect of tobacco advertising on tobacco consumption. A dis­
cussion document reviewing the evidence (the Smee Report).

London: Department of Health, Economics and Research
Division, 1992.

23.

Brundtland GH. Influencing environmental factors in car­

diovascular disease prevention: A global view. Preventive
Medicine 1994; 23 (no. 4): 531-4.

17

Tools for Advancing Tobacco Control

in XXIs* century:

Success stories and lessons learned

Outils pour poursuivre la lutte antitabac

au XXIsiecle:

Experiences concluantes
et nouveaux enseignements

Labelling and Packaging
(including Health
Warnings)

™H—
pn-is-zs

Canada's Tobacco Package Label
or Warning System:
"Telling the Truth" about Tobacco Product Risks

Tobacco Free Initiative would like to thank
the Centers for Disease Control and Prevention (CDC), Atlanta, USA

for their generous support for this project.

© World Health Organization 2003
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Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or rec­
ommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors
and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

The World Health Organization does not warrant that the information contained in this publication is complete

and correct and shall not be liable for any damages incurred as a result of its use.

The named authors alone are responsible for the views expressed in this publication.

Printed in World Health Organization, Geneva.

Canada's Tobacco Package Label
or Warning System: "Telling the Truth”
about Tobacco Product Risks
Garfield Mahood
Non-Smokers’ Rights Association

and the Smoking and Health Action Foundation

Toronto, Ottawa, Montreal

World Health Organization

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

WHO Regional Office for Africa (AFRO)

Cite du Djoue
Botte postale 6

WHO Regional Office for Europe (EURO)
8, Scherfigsvej

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Telephone: +(45) 39 17 17 17

Telephone: +(1-321) 95 39 100/+242 839100

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Telephone: +(91) 11 337 0804 or 11 337 8805

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Abdul Razzak Al Sanhouri Street, (opposite Children's

1000 Manila

Library)

Philippines

Nasr City, Cairo 11371

Telephone: (00632) 528.80.01

Egypt
Telephone: +202 670 2535

Canada's Tobacco Package Label or Warning System: "Telling the Truth" about Tobacco Product Risks

The Need for an Effective
Package-Based Label System

premature death of 3 million Canadians from among this

country’s 32 million population.(4) Such predictions of

enhanced mortality of this magnitude necessitate extraor­
The World Health Organization's draft Framework

Convention on Tobacco Control (FCTC) will be presented
to the World Health Assembly in May 2003. Its call for

dramatically improved tobacco warnings worldwide

reflects growing interest in tobacco package labelling
or warning systems (1). This interest is augmented by
greatly improved warnings now appearing on the shelves

of retail outlets throughout the European Union, and by

the announcements of other countries, such as Malaysia,
of the planned introduction of reforms modelled on the
Canadian or Brazilian warnings.

This heightened interest created by the FCTC proc­
ess, and the encouragement it provides to parties to the
Convention to implement more effective warnings, raises

significant questions. Why are bigger and bolder warnings
better? What messages are most effective? What tactics
might be expected from an industry determined to under­

mine any measure that might cut its sales?
Canada has been one of the pioneering countries in devel­
oping and implementing innovative labelling requirements

for tobacco products. This Country Report on warnings

has been prepared in the hope that it will make a timely
contribution to the development of similar reforms in other
countries. Though some aspects of Canadian warnings

dinary public health interventions.

In the case of major epidemics caused by viruses or bac­
teria, governments have a duty to provide clear, full infor­

mation to their citizens on the seriousness of the diseases
and how to avoid them; this general duty applies equally

to tobacco. However, tobacco is unique among major epi­

demics in possessing its own public relations department,
the tobacco industry, which has a vested interest in ensur­

ing that consumers know as little as possible about the dis­
astrous health effects of addiction to tobacco products.

Though the details of consumer protection law vary widely

from country to country, there is widespread agree­
ment on general principles, as exemplified by the United
Nations' Guidelines for Consumer Protection These guide­

lines recognize the right of consumers (a) to be protected
from health and safety hazards in the marketplace and
(b) to be given "adequate information to enable them to
make informed choices" - including choices about risk.(5,)

Historically, the marketing of tobacco products has grossly
violated both of these principles. Consumers have been

exposed to extremely large risks: mortality rates of 50 per

cent for long-term users of tobacco.("6) They have not
been provided with accurate information.

are now well known, particularly the use of images, the

In Canada, tobacco manufacturers have had a longstand­

debate and analysis that led Canada to move ahead in this

ing duty at common law to warn their customers of the

area are less well understood. The gradual move towards

risks associated with their products. This duty requires

large, explicit and graphic health messages came about

tobacco companies to warn of both the nature of the risks

because of a deepening understanding of the misinforma­

(e.g. over 20 debilitating or terminal diseases alone (7))

tion and deception that underlie the tobacco epidemic.

and the magnitude of the danger (e.g. about 85 per cent

of the time, lung cancer causes death, usually within two
The right to be warned

years (8J). The Ontario Court of Appeal, described the
duty of all manufacturers to warn as follows:

The tobacco epidemic has rightly been described as a glo­
bal catastrophe of unparalleled proportions: unless extraor­

Once a duty to warn is recognized, it is manifest that the

dinary public health interventions occur, tobacco products

warning must be adequate. It should be communicated

will kill 500 million people among those alive at present.

clearly and understandably in a manner calculated to

(2) In other words, a single product category will kill about

inform the user of the nature of the risk and the extent of

ten times the number of civilian and military casualties

the danger; it should be in terms commensurate with the*

from the Second World War, even if future generations
reject tobacco industry products.1

World War II. Encyclopaedia Britannica 2003.

In the Canadian context, about 45 000 smokers die annu­

Encyclopaedia Britannica Premium Service, Accessed

ally from the tobacco epidemic/3) In fact, Health Canada,

23 April 2003. http://www.britannica.com/eb/

which is the federal health department, estimates that

article?eu=118868

the products of tobacco manufacturers will cause the

World Health Organization

gravity of the potential hazard, and it should not be neu­

The need to cut through cognitive dissonance, and to

tralized or negated by collateral efforts on the part of the

communicate effectively with children and teenagers,

manufacturer. (9)
Warnings of the nature and magnitude of risks are two

clear responsibilities in Canada's consumer law. A third
important principle of consumer protection is that the duty
to warn may take different forms depending on the buy­

ers (or prospective buyers). For example, in the case of a
product designed for use by blind people, a manufacturer

would have difficulty escaping liability for product hazards
by pointing to a written warning included on the product.
More generally, consumer protection law makes special
efforts to protect various types of vulnerable groups.
Children are particularly vulnerable to deception or exag­

gerated advertising claims and usually cannot legally enter
into major contracts, because they are deemed unable to

judge reliably what is in their best interests. As well, peo­
ple who are afflicted with terminal diseases are particularly

vulnerable to advertising for "miracle cures".

helps explain why Canadian tobacco-control policy has
moved from occasional education campaigns, via print-

only information on packages, to the present system of
large, graphic-based warnings. Further, to help reduce

cognitive dissonance, the new health information system
includes help for smokers wanting to quit: clearly, it is
easier to absorb health information if there is some hope

that you can do something about your addiction.

The debate over warnings goes back almost three dec­
ades in Canada. The fact that the industry negotiated a
weak, on the face of it absurd voluntary warning which

was in effect from 1975 to 1988 ("The Department of
National Health and Welfare advises that danger to health

increases with amount smoked. Avoid inhaling") does

not negate the industry's tort or civil law obligations dur­
ing this period. Clearly, a voluntary agreement does not
cancel the longstanding obligations that the industry has

to its customers in civil law. Nor does Canada's new warn­
Tobacco marketing is largely directed towards two such

ing system give the industry complete sanctuary if current

vulnerable groups: children/teenagers (who must be

Canadian warnings are found to be inadequate. Section 16

enticed to take up smoking if the industry is to replace

of Canada's Tobacco Act2 under which current warnings

customers who die or quit), and addicted adults. In the

are mandated says:

case of teenagers, the vulnerability is obvious: with good

reason, society does not expect them to be able to make
an informed choice between the promise of immediate

if symbolic rewards (i.e. social acceptance and identity)
and the prospect of dire consequences in a few decades'

time (i.e. death in middle age). Nor is it realistic to expect

dry, scientific information to compete with the emotional
impact of well-crafted imagery.

In the case of addicted smokers, the vulnerability to mis­

This part does not affect any obligation of a manu­
facturer or retailer at [civil] law or under an Act of
Parliament or of a provincial legislature to warn
consumers of the health hazards and health effects

arising from the use of tobacco products or from
their emissions.

This section of Canada's tobacco statute preserves the civil
law duty to warn, which could be more onerous than the

information comes from the phenomenon of cognitive

duty spelled out in the new warning regulations. This sec­

dissonance: it is very difficult to go on believing one thing

tion was in part a reaction to the tobacco industry's often

while doing the opposite. Specifically, for a smoker who

successful use of federal labelling legislation in the United

is physiologically unable to refrain from smoking his or

States of America as an argument to escape liability in that-

her next cigarette, there is a strong tendency to discount

country's courts ("The Congressional Shield"). The United

information about health risks - and to fall for pseudo­

States courts have ruled that American warnings legislated

arguments typically provided by the tobacco industry.

by Congress protect the manufacturers from the respon­

("It hasn't been proven that smoking causes cancer" and

sibility of providing more meaningful warnings than those

"Tobacco is addictive in the sense that drinking soda pop

presently in use. It has been successfully argued that if

is addictive", etc.).

Congress had wanted stronger warnings. Congress would

have mandated stronger warnings.
Thus, regardless of the perceived strength of the
Available on-line at http://laws.iustice.gc.ca/en/T-11.5/

index.html.

Canadian warnings now, tobacco manufacturers long
had a civil law duty to warn - which they ignored. Judge

Andre Denis decided in 2002 to throw out the tobacco

Canada's Tobacco Package Label or Warning System: "Telling the Truth" about Tobacco Product Risks

industry's constitutional challenge to the Tobacco Act and

package, including the deception related to the marketing

Canada's landmark tobacco package warning system.

of the family of low tar cigarettes, the 'light' and 'mild'

Using remarkably strong language rebuking the manufac­

consumer fraud. (12, 13) However, to the extent that any

turers, he observed:

The duty [to warn effectively] must be imposed
because the tobacco companies have continuously
failed to fulfil their obligations in this respect [in

civil law], despite their knowledge of tobacco dan­
gers...The industry knew this [tobacco's harms],
but said nothing."(7Q)

remaining colour and design on Canadian tobacco packag­
ing suggests that the product is safer than it is or under­

mines the warnings of risk, that deception should also be
removed. This objective will probably move health policy

inexorably towards plain packaging (see text below).
Ancillary benefit to an effective
warning system

So it was, in the face of this decades-long failure to warn

Although some governments have taken steps to reduce

adequately, that the government forced the industry to

tobacco advertising and promotion, most have ignored

implement Canada’s first generation of world precedent­
setting tobacco warnings in 1994.

Increasing Information about
Tobacco Risks and the Elimination
of Deception
Tobacco products are extraordinary in a number of
respects. One of them is the unique nature of the product

the lynch-pin of tobacco marketing, the package itself. All

tobacco advertising, sponsorship and point-of-purchase

promotion relates ultimately to the colour and graphics or
trade dress of the package, like spokes are connected to
the hub of a wheel. However important the packaging has
been to the industry to date, as advertising bans increas­

ingly take effect, the manufacturers will focus even greater

attention on the package itself.(14)

in terms of risk. Tobacco is addictive to children and has

In Canada, there are 2 thousand million packs sold annu­

no safe level of use. Tobacco products kill on an extraordi­

ally, each one a miniature ad display. Each time a package

nary scale, causing the death of nearly one out of two of

is pulled from a pocket or purse, about 20 times a day

their long-term users/? 1) Despite this, governments have

for the average smoker, it creates an advertising impres­

allowed such products to be marketed in some of the most

sion. Tobacco packages place about 40 billion ad impres­

sophisticated and alluring packaging or trade dress ever

sions into the Canadian market every year, a total that

developed. The message to users and to potential child

undoubtedly dwarfs the value of other tobacco promo­

and adolescent starters sent via the design and graphics

tions and advertisements. It is a legitimate health goal for

of the package has been that the product inside is normal,

governments to use large warnings to draw attention to

legitimate and safe.

the messages and to increase knowledge of risks. If the

An effective package-based label and warning system can
do much to counter the implicit reassurance provided by

alluring packaging. In fact, because of the perfect target­
ing for these labels, the immense size of the target audi­
ence (in Canada, 5 million smokers, and their families)

and the low cost of the measure, such a warning system
has the potential to become the most cost-effective public

health education campaign the country has ever seen.
There are at least two purposes of warning labels. First, as

stated above, any warning system must inform potential
and actual users of both the nature of tobacco risks and

size of such messages coincidentally reduces the industry's
ability to use the remainder of the package for the decep­

tion that is implicit in the alluring packaging, public health
will benefit again. Even if governments, for any reason,

feel they cannot use large warnings solely to diminish the
promotional power of tobacco trademarks or package

trade dress, they should be aware that, at a minimum, the

reduction of this power is an ancillary health benefit.
The value of reducing the trademark's promotional power
was acknowledged by the Quebec Court in its decision.
Judge Denis wrote:

the magnitude of those harms, including the prognosis

Warnings are effective and undermine tobacco

should a given tobacco-related disease strike.

companies' efforts to use cigarette packages as

The second purpose is less well understood than the first.

Any effective warning system or package reform gener­
ally should also remove any deception that is part of the

badges associated with a lifestyle [i.e. an adoles­

cent badge suggesting entry into adulthood]/75)
5

World Health Organization

Levels of Awareness of Tobacco Risks

Finally, there is evidence from various countries that some
smokers may have a distorted perception of the health

Despite recent claims by tobacco manufacturers that their

risks of smoking compared with other health risks."

industry is now climbing to new heights of social respon­

(emphasis in original)(77)

sibility, much offensive behaviour continues as before.
For example, in the Rothmans 2002 Annual Report 3,
Rothmans Benson and Hedges says:

It was in the absence of acceptable levels of awareness
among starters and users that Canada implemented seri­

ous tobacco warnings reform in 1994.

RBH acknowledges the health risks which have
been associated with smoking. The choice to

The Context for Warnings

smoke is made with full awareness of these risks
which have been widely known for decades.

tn the early 1980s, Canada had the highest rate of per

(emphasis added)

capita tobacco consumption in the world.(7 8) However, in
the decade following 1983, the country experienced rapid

By claiming that its products are only "associated with"

decline in per capita consumption, including a 34 per cent

disease, the manufacturer maintains the fiction that it has

drop in the seven years to 1990.4 The fall in teen smoking

not been proven that the tobacco/disease relationship is a

rates was particularly dramatic, with prevalence rates virtu­

causal one. In fact, research reveals precisely the opposite

ally halved between 1981 and 1992.(79)

of what this passage asserts.

A number of factors contributed to this reduction, includ­
The literature shows that many smokers, including child

ing the national debates over and enactment of two land­

and adolescent starters, are generally aware that tobacco

mark tobacco control bills, the Tobacco Products Control

industry products are "bad for you". But scratch below

Act (TPCA) and the Non-smokers' Health Act (NsHA) in

this superficial level of awareness and you will find a

1988, and the passage of municipal by-laws to regulate

knowledge level that is clearly inadequate for such a lethal

smoking in public areas and workplaces. The TPCA banned

product/? 6)

tobacco advertising and sponsorship. (Unfortunately, a

The World Bank addresses the level-of-awareness issue:

loophole in the law gave the manufacturers an opportu­

An overview of the research literature recently

to expire in October 2003.) The NsHA effectively banned

concluded that smokers in high-income countries

smoking in federally-regulated workplaces (about 9 per

are generally aware of their increased risks of dis­

cent of all workplaces), including federal buildings, banks,

nity to continue sponsorships to date. The loophole is set

ease, but that they judge the size of these risks to

air and rail transportation and Crown corporations.

be smaller and less well-established than do non-

smokers. Moreover, even where individuals have a

These valuable legal reforms were preceded by aggres­

reasonably accurate perception of the health risks

sive tobacco control advocacy. Undoubtedly, both the

faced by smokers as a group, they minimize the
personal relevance of this information, believing

other smokers' risks to be greater than their own.

public debate and the law reform that followed reduced
consumption. However, the single most important factor
in the declines in consumption was likely the equally steep
increase in tobacco taxation at the national, provincial and

territorial levels from 1983 to 1991. (20)

Unfortunately, much of the momentum and some of the
3

Available on-line at http://www.rothmansinc.ca/English/
2002/Annual_Report/RINC.02.Colour.Eng.pdf.

4

NSRA calculation from Statistics Canada data on domestic

sales of cigarettes and roll-your-own tobacco, and on
population 18 years and over.

5 Joy de Beyer, World Bank, presentation to the
International Conference on Illicit Trade, New York, July/

August 2002.

health gains during this 10-year period were lost in 1994
when the federal government and several of the provinces

made substantial cuts in tobacco taxes to combat smug­
gling promoted by the tobacco industry.5 (27, 22)

The "half-price cigarettes" that resulted in much of
Canada were the first of two major setbacks that slowed

the remarkable momentum in tobacco control which
had been building. The second was the loss in 1995 of

the TPCA when the Supreme Court of Canada ruled, 5

Canada's Tobacco Package Label or Warning System: "Telling the Truth" about Tobacco Product Risks

votes to 4, that this legislation was unconstitutional. The

in much of Canada following the tobacco tax reductions.

Tobacco Act which replaced the TPCA in 1997 is the cor­

Unfortunately, the appearance of the new warnings made

nerstone of the federal government's legislative response

it more difficult to measure the negative impact of the tax

to the tobacco epidemic. This statute bans most advertis­

cuts independently of the positive gains from the improved

ing and gives the government extensive power to regulate

warnings.

the tobacco industry, including the labelling of tobacco
products.

By world standards, the labels produced in 1994 were

indeed impressive, setting global precedents for tobacco

In late 2000, as the latest generation of Canada's land­

warning systems.(26,) The warnings, excluding borders,

mark labels or warnings started to appear in the market,

were the largest in the world (25 per cent of principal dis­

24 per cent of Canadians aged 15 years or more reported

play areas) and the first to appear on both major faces of

smoking, and 20 per cent were daily smokers. Smoking

the package: English text on one face and French on the

prevalence was higher among men than women: 26 per

reverse. The warnings plus borders occupied as much as

cent as compared to 23 per cent. Smoking among teenag­

40 per cent of each major face of the package one entire

ers aged 15-19 was 25 per cent.(23)
A series of tobacco tax increases in 2001 and 2002 has
made it difficult to tease out the specific impact of warn­
ings on consumption. Per capita tobacco consumption
in 2002 was down a whopping 8.1 per cent on 2001.

side panel. Of considerable importance, these warnings

were placed at the top of the major faces, the premier

location on the package.
The tobacco industry was also forced by these warnings

into a black-and-white format, which prevented the man­

It would defy common sense to conclude that the new

ufacturers from camouflaging the warnings in the package

warnings had no role in such a remarkable decline.6

colours. Half of the time, the warnings were printed with
black lettering on a white background with a 3 mm black

Canadian Warnings: 1994 Generation
With the passage of the TPCA in June 1988, Health

border. For the other half, the law required the opposite:

white lettering on a black background with a white bor­

der, the graphic format that the industry found the most

Canada planned strong tobacco warnings including a

distasteful.

world precedent-setting warning of tobacco addiction. But

There were other breakthroughs in the 1994 warning sys­

in a secret meeting with senior bureaucrats, tobacco lob­

tem. For the first time, a causal relationship between the

byists negotiated away the addiction warning and other

product and disease was recognized in a tobacco warn­

reforms that would have revolutionized tobacco warn­

ing ("Cigarettes cause cancer”). These warnings were the

ings/?^ The result was a warning system which incoming

first to transfer the responsibility for the epidemic from

health minister Perrin Beatty said was so artfully hidden in

individual behaviour (smoking) to the industry's products

the package colours that the tobacco industry could have

("Cigarettes cause cancer"), the first to the warn of addic­

taught the Canadian military lessons in ''camouflage." (25)

tion ("Cigarettes are addictive"), the first to establish envi­

In an appropriate response, Mr Beatty announced the
first generation of Canada's landmark warnings in 1990.

Almost immediately, this reform stalled. The delay was

caused by a risk-averse approach to implementation relat­

ed to the tobacco industry's constitutional challenge of

ronmental tobacco smoke as the cause of terminal disease

("Tobacco smoke causes fatal lung disease in non-smok­
ers"). Given the noteable departure from the largely invisi­
ble warnings that preceded them, these dramatic warnings
shocked the country when they first appeared.

the TPCA. The Non-Smokers' Rights Association (NSRA),

The focus on tobacco packages did not end with these

Canadian Cancer Society (CCS) and the Heart and Stroke

changes. When tobacco taxes were cut in 1994 in order to

Foundation of Canada then led a three-year campaign for

price smugglers out of business, the House of Commons

enactment including a letter mailed to one million house­

health committee was asked to review the sale of tobacco

holds in the constituencies of federal cabinet ministers.

The black and white, text-based warning system finally

6

Comparing 2002 (Jan-Dec) with 2001, per capita con­

appeared on cigarette packages in 1994. The new warn­

sumption of cigarettes plus roll-your-own (assuming 0.7g

ings undoubtedly blunted, to some degree, the extremely

of ryo = 1 cig) was down 8.1 %.

negative effects of the almost half-price cigarettes available

in plain packages. (Plain packaging is defined as packaging

soft packs to avoid carrying the interior warning/cessation

on which the surface graphics currently used to differenti­

system.

ate brands have been standardized.(27) Plain packs incor­
porate a standard package base colour and are stripped

Exterior warnings

of any trademark colour, graphics and language.) Early in

The regulation requires 16 warning labels in rotation which

1995, the committee recommended plain packaging (28)

use full colour, pictures and graphics7. These labels occupy

but tobacco lobbyists worked hard to stall this reform. A

the upper 50 per cent of both of the "principal display

focused advocacy campaign would be required to force

surfaces” of each package: English on one side, French on

the implementation of this recommendation.

the other (Canada's two official languages). These are the
warnings that have captured international attention.

Canadian Warnings: 2000 Generation
Considerable focus-group testing and polling went into
Enactment and implementation

determining both the size and the format of the exterior

warnings. Smokers consistently reported that warnings

The latest iteration of Canada's warnings was implement­

with images were far more likely to influence their behav­

ed by the then health minister Allan Rock under Section

iour, and that of youths who might be tempted to start

15 of the Tobacco Act and implemented by way of regu­

smoking. They also reported that larger warnings would

lation in June 2000. The law required that about 50 per

be more effective in encouraging them to quit. Initially,

cent of tobacco packages had to have the new warnings

the government announced warnings that would occupy

in place within 6 months from enactment. Any remain­

60 per cent of both major faces. Subsequent research sug­

ing packaging had to comply within 1 year. This gave the

gested that warnings of 80 per cent would be even more

industry some flexibility related to problems of produc­

effective.("29) Despite this, in the trade-off that normally

tion and clearance of inventory. The regulation dictated

accompanies political decisions of this kind, the health

the labelling of tobacco products sold in individual pack­

minister settled for warnings occupying the upper 50 per

ages, cartons and tubs, and applies to products produced

cent of both major faces. These measures set global prec­

domestically and imported.

edents in both size and content.

Two distinct warning systems

Interior warnings

Canadian cigarette packages consist of three types. The

Health Canada made only a modest effort to realize the

most common package in Canada - though it is virtually

potential of the interior system. It consists of 16 messages

unknown elsewhere - is the shell and slide design which

in rotation printed on either the slide of the dominant

accounts for over 85 per cent of the Canadian market. The

package type, or on a removable insert for the flip-top

slide surrounding the cigarettes moves up and down inside

box. When the interior system was originally recom­

the outer shell on which most of a company’s trade dress

mended to Health Canada by health groups, it was sug­

is printed. The package with about 10 per cent of the

gested that any messages rotated on the inside should be

market is a flip-top box, common in other markets. Soft

a "surprise" to the smoker, which would only be revealed

packs, the third type of pack used, account for less than 1

after the purchase was made. Because of this feature, the

per cent of sales.

There are two distinct warning systems in the new

Canadian labels for manufactured cigarettes: (a) an exte­

impact of the interior messages would only be limited by

the obvious requirement of scientific and legal validity and

the skills of the advertising creative team.

rior system printed on the shell of the most common pack­

Considering Health Canada was breaking new ground

age and on the outside of the flip-top box or soft pack; (b)

with these warnings, and that the Tobacco Act under

an interior system printed on the slide or on a leaflet which

which the warnings were being implemented was under

is inserted inside the flip-top package. As explained below,

some tobacco products that occupy a small segment of the

market face less stringent requirements. For example, a

8

7

See "Images of Canadian Health Warnings,” at

loophole given to manufacturers exempts soft packs from

http: //ww. nsra -adnf. ca/news_

the leafletting requirement imposed on flip-top boxes.

lnfo.php?cPath=22&news_id=78

This could encourage manufacturers to shift production to

Canada's Tobacco Package Label or Warning System: "Telling the Truth” about Tobacco Product Risks

attack in the courts, the development of the interior sys­

monoxide and nicotine, as measured by machine using

tem proceeded with some timidity. These restraining influ­

International Organization for Standardization (ISO) test­

ences caused the interior messages to be limited to high­

ing parameters.

lighted text without full colour, pictures or graphics.

0

It was by then well established that ISO numbers do

Whatever the limitations of the interior system in this

not provide meaningful information on quantities of

generation of warnings, the government did establish the

toxins absorbed by smokers - a 'light' cigarette can eas­

precedent of using the inside of the pack. This gave Health

ily give the same amount of tar as a 'regular' one, as

Canada the potential to develop this system more fully in

smokers adjust puff volume and other characteristics to

the future.

achieve their habitual nicotine dose. The government had

developed a new set of testing parameters, designed to
Messaging

Tobacco industry documents reveal concern about effec­

approximate yields under realistic conditions of smoker

compensation.

tive warnings. One Bitish American Tobacoo (BAT)

The decision was made that the new 2000 format would

document says, "There should be no specific mention

include a range that would show the yields of both the

of smoking related disease" in warnings. (30) Another

ISO and "realistic" parameters. While this approach makes

says, "Reference to specific diseases on health warnings

it less easy to tie misleading marketing devices, such as the

should be resisted strongly."(37J Industry objections not

'lights' moniker, to officially sanctioned tar yield numbers,

withstanding, the exterior warnings speak to specific risks:

it is still far from satisfactory.

addiction, lung cancer (two messages), heart disease,

emphysema, mouth disease, stroke, second-hand smoke
(three messages), maternal smoking during pregnancy
(two messages), effect of parents' smoking on the risk of

uptake among children, a warning of hydrogen cyanide,
and a "proportionality" message (deaths from tobacco

compared with other causes of preventable death).
The 16 interior messages include the following: nine posi­

tive messages to encourage cessation (beginning "You

CAN quit smoking!”) and seven more detailed messages
to complement the exterior warnings introduced by ques­
tions such as:
— "If I get lung cancer, what are my chances of surviv­

The range between the results from the two test methods

is considerable, particularly in the case of highly venti­

lated cigarettes8. To the extent that smokers optimistically
believe their personal exposure level to be near the lower
end of the range, they may assume a health benefit to
brand-switching where actually none exists.9

Canadian health organizations recommended that the ISO

numbers be dropped altogether. However, Health Canada
was reluctant to abandon the ISO system completely,

which the government had embraced for many years.
Nevertheless, health groups expect changes in the next

generation of warnings. In the meantime, Health Canada

has added three new toxins in tobacco smoke that the

ing?"

— "Can second-hand smoke harm my family?"
— "Can tobacco cause brain injury?"
8

To ensure print quality control, the regulation specifies that

See “Toxic constituents information" at http://www.nsraadnf.ca/newsJnfo.php?cPath=22&news_id=187.

the "warnings and health information" must be obtained

from electronic images obtained from Health Canada and
that the quality must be "as close as possible to the col­

our" set out in Health Canada's source document.

9

For example, in the popular brand family Player's, Player's

Filter (i.e. regular) has a tar rating of 15-33 mg. Player's

Extra Light has a rating of 11 -29 mg. The newly intro­

duced Player’s Silver has a range of 8-27 mg. Somebody

The toxic constituent panel

switching from regular to Silver would quite naturally

assume that in the process they reduced their exposure

In addition to the package faces occupied by the warning
systems described above, one side panel of each pack­

substantially, possible by as much as 50% (from 15 to 8

mg, say). In fact, they are likely at the lower end of the

age carries information about machine-measured yields

range when they smoke the regular and at the higher end

of various smoke constituents. In the warnings introduced

when they smoke the Silver, e.g., 20 mg in either case.

in 1994, yields of three toxins were listed: tar, carbon

9

World Health Organization

industry must now report in the toxic constituent panel:

This ordering of the language forms a word block and

benzene, hydrogen cyanide and formaldehyde.

allows the dissonant smoker to ignore the rest of the

Health Minister Rock published a Notice of Intent to
Regulate in 2001 to signal the intent to ban 'light' and

warning. Therefore, the attribution to "Health Canada" in

small typeface was wisely placed below the warning.

‘mild’ descriptors. However, to date, with a change in

To Health Canada's credit, it also rejected an attempt

ministers, this reform seems stalled.

by the tobacco industry to slip in the following message

"Underage sale prohibited." The government recognized
Pipe tobacco and cigars

that industry attempts to position its products as "for

These tobacco products occupy a very minor part of the

adults only” encourages youth to attempt to use cigarettes

Canadian market and have less stringent warning require­

as a "badge" signifying entry to adulthood.

ments to meet. Manufacturers must rotate four bilingual

warnings with pictures, colour and graphics. Bidis, chewing

Wear-out

tobacco, oral snuff and nasal snuff carry four text-only

Warning labels become stale with the passage of time. To

messages in rotation.

address problems related to obsolescence or "wear-out",

at the time of enactment of the 2000 generation of warn­

Cartons and kits

ings, the government committed to changing and refresh­

Each carton must carry one of 16 warnings in rotation

ing the warnings within three years.

which occupy 50 per cent of the surface area of every
face. This requires each carton to have three warnings in

English and three in French chosen from among the 16

exterior warnings required on individual packages. Because
every face of the package has a warning, the manufactur­

ers and retailers are prevented from stacking cartons in
such a way as to create a large, warnings-free cigarette

display at point-of-purchase.

Marker words

Success of the Intervention
The purpose of the intervention was to provide current
and potential smokers with accurate information, compel-

lingly presented, with respect to the nature and magnitude
of the risks of tobacco products. In the face of the contin­
uing tobacco epidemic, the government sought to address

at least partially the manufacturers' ongoing failure to
provide full and accurate risk information. Clearly, it will

take many years before the effects of decades of omission

A typical feature of warning labels and signs is the use

of marker words such as "CAUTION", "WARNING",

and misrepresentation are overcome; but access to proper

warnings is a public benefit in itself.

or "DANGER". Almost all of Health Canada's messages
utilize "WARNING" or "AVERTISSEMENT". The marker

The short-term impact of the warnings on consumption

word "CAUTION" is not strong enough for a product that

or smoking rates is impossible to quantify, because of a

kills and has no safe level of use. "DANGER" suggests that

number of other tobacco control measures, such as tax

the hazard or risk is immediate or imminent; this marker

increases, workplace smoking bans and mass media cam­

was therefore thought to be inappropriate. Markers are

paigns that were implemented virtually simultaneously.

often highlighted in some way. Graphically, it was thought

However, smokers and recent ex-smokers are surpris­

that "WARNING" or "AVERTISSEMENT" in red or yel­

ingly numerous in reporting that the new warnings were

low was most effective depending upon the background

"a factor" or "a major factor" motivating a recent quit

colour. For example, red markers disappear on black back­

attempt.10

grounds in some Canadian warnings. Yellow should have

been used.
10

10

A total of 38%, according to a survey conducted in

Attribution and extraneous messaging

October 2001. See Environics Research Group, Evaluation

Health Canada rejected the language encouraged

of new warnings on cigarette packages (Research pre­

by the industry, whereby the authority to which the

pared for the Canadian Cancer Society). Available on-line

warning is attributed leads the message; for example,

at http://www.cancer.ca/vgn/images/portal/cit_776/35/

"Surgeon General's Warning: Smoking causes..." or "The

20/41720738niwJabelstudy.pdf

Department of National Health and Welfare advises.

Canada's Tobacco Package Label or Warning System: "Telling the Truth" about Tobacco Product Risks

What the research shows

a secret presentation given to directors and advisors of the

In general terms, smokers are saying, "Give us the truth,

goal of the plan was "to stall and, ultimately, significantly

Canadian Tobacco Manufacturers' Council in 1999. One

however uncomfortable, anything that will help us get

amend government's proposed regulations on packaging

off cigarettes." (32) Quantitative and qualitative research

and point-of-sale." The document makes clear the need

completed both before and after enactment of Canada's

to organize unions in opposition and to "coordinate anti­

new warnings shows that:

— smokers and potential starters have an imperfect
understanding of the nature and magnitude of the
risks of tobacco use (33);

— large warnings with pictures and graphics in colour are
seen as crucial, first, in attracting attention to messages

packaging campaign with key suppliers." (42)
A variety of arguments were employed. It is worth under­
lining that the content of the warnings was not at issue.
The manufacturers said they would not contest the lan­

guage, presumably because they could not win such a
protest. Attempts to block the reform focused on:

(34) and, second, in increasing the desire to quit smok­

ing (35);

— emotive messages are often more effective than statis­
tics (36);

— personalized messages are more effective than imper­

sonal ones (37);
— messages about risks which have a component involv­
ing personal appearance have a greater impact (e.g.
Canada's warning about mouth disease) (38);

— positive messages related to cessation assistance in
conjunction with strong risk messages are more effec­
tive (39). Not unexpectedly, if anxiety about risk is

raised, suggestions that offer hope of avoiding the risk
are warmly received;

— after a few months on the market, package warnings

— the constitutionality of taking 50 per cent of the pack­
age's trade dress, an alleged infringement of the indus­

try's commercial freedom of speech,
—■ the claimed inability of the printers, using a rotogra­

vure printing process, to meet the requirements of
Health Canada to produce both full colour warnings

and the sophisticated printing demands related to

industry trademarks, and
— the threatened loss of jobs when printing contracts
moved to the United States.
However, unlike in the plain package debate, alleged vio­

lations of international trade laws and of intellectual prop­
erty rules did not feature prominently in the political fight

over the warnings.

had high visibility and were rated a "top-of-mind"

source for health information. (40)

Pressuring the government to proceed and countering
the various industry blocks was a coalition of over a 100

The Quebec Superior Court reviewed the evidence about

national and regional health and human service organiza­

the efficacy of the warnings and concluded the "warnings

tions led by the NSRA and the CCS.

are effective." Judge Denis said:

Threats related to constitutional issues were countered by
A study commissioned by Rothmans, Benson &

lawyers acting for the federal Attorney General and the

Hedges Ltd. (R.B.H.) in the year 2000 (Project

CCS. To counter the block created by the printers and

Jagger, June 23, 2000) mentioned in Dr. Pollay's

their clients, the health organizations enlisted the aid of

report shows that the warnings with photos recent­

printing experts. Health Canada showed leadership by

ly mandated by the federal government are having

manufacturing cigarette packages which proved that the

a major impact on consumers." (emphasis added)

warnings could be produced while protecting the manu­

(41)

facturers' trademark colours.

Attempts to Block Labelling Reform

Curiously, as soon as the warnings were approved by par­

Opposition to the labelling reform came from three princi­

The manufacturers did follow through with their legal

pal sources: the three major Canadian manufacturers, the

assault on the warnings. This argument was rolled into

Canadian Tobacco Manufacturers’ Council, and tobacco

the constitutional challenge of Canada's Tobacco Act then

liament, the issue of job losses disappeared into the ether.

package printers who were either incited or frightened by

underway. In December, Judge Denis said the rights of

their manufacturer clients. This followed a plan outlined in

the industry under the Charter "cannot be given the same

11

World Health Organization

legitimacy as the government's duty to protect public

the development of an outstanding system. First, we had

health" and rejected all of the industry’s challenges.(43)

a unified health community pressing for the initiative,
developing a prototype of a breakthrough system, (45)

Factors Leading to Enactment
in 2000

conducting research (46) and generating counter pres­

In the real world of tobacco control, many factors influ­

were committed to the reform and who provided the

sure to the opposition from the tobacco industry. Second,
there was a health minister and a key ministerial aide who

ence the formation of policy and the final form of inter­

political leadership so very essential for enactment. Third,

ventions. In an observation attributed to Bismarck, it is

there was a team within Health Canada charged with

said that there are two things one might not wish to see

the responsibility to see this project to completion which

in production: sausages and laws. Several factors impacted

worked hard and with commitment to move the warn­

on the development of the Canadian warnings and not all

ings to completion. In the absence of leadership from any

of them were health based. Prior to the announcement of

of these three interests, the new warnings may not have

health minister Rock’s plans for new warnings, his govern­

come to fruition.

ment had been severely criticized for concessions given
on tobacco sponsorship to international motor-racing.

Although the minister had little to do with the conces­
sions, he was an activist minister and wanted to make a

positive contribution to the development of the tobacco

file. After receiving a thorough briefing on the impor­
tance of tobacco warnings and the role of the package in

Recommendations
Our experience with the warnings reform process suggests

the following recommendations:

1.

he decided in 1999 to proceed with improvements to the

information about specific diseases and the prognosis if

package warning system.

a tobacco disease strikes.

The NSRA, CCS and Physicians for a Smoke-Free Canada

2.

information should not overwhelm the purpose of the

the 2000 warnings reform. In particular, the NSRA manu­

warning system expressed in point 1 above.

factured a prototype warning system (44) and the CCS
contributed valuable research on a variety of issues related

Cessation information that offers hope works well
when it follows anxiety-raising warnings. But cessation

led non-governmental organization (NGO) advocacy for

3.

Risks of disease should be attributed to the prod­

to the new warnings. Health Canada conducted its own

uct (e.g. cigarettes), not to individual behaviour (i.e.

research including research on recommendations originat­

smoking). Cessation messages can focus on individual
responsibility.

ing with the NGO community.
Because the changes being planned were substantial, time

4.

of great interest to them. Spouses, children and friends

the final product was influenced by legislative time con­

of non-smokers read the warnings and encourage

straints, lack of optimal time for research and testing, risk

smokers to quit

averseness related to litigation, and uncertainty with respect

to how intrusive the warnings could be. For example, the

5.

6.

7.

be attributed to factors not always acknowledged in the
development of public policy and we stress their impor­

Personalized messages work best, for example,
“Cigarettes can kill you!’’.

went further than any other tobacco labelling system in

any country at the time. This success may in large part

Warnings should be introduced by an appropriate
marker, such as WARNING.

Despite these problems, the product that emerged in
late 2000 was a precedent-setting system, a system that

Warnings should be large and utilize blunt language,

pictures, colour and graphics.

failure to commit to a complete interior warning system
earlier in the process affected the quality of that system.

Non-smokers should not be overlooked as targets of
any warning system. Second-hand smoke warnings are

constraints soon became a factor. In the rush to completion,

12

Select warnings that cover the nature of the risks and

the magnitude of the danger. Warnings should provide

tobacco marketing by a non-governmental health agency,

8.

Weasel words such as "is related to", “is linked to" or
"is associated with" should be rejected to the extent
that science permits. Identifying causation is important,

tance. There were three key influencers in the system

for example, “Cigarettes can cause lung cancer, in

working cooperatively and with commitment towards

you!”.

Canada's Tobacco Package Label or Warning System: "Telling the Truth" about Tobacco Product Risks

9.

Blocks in warnings created by difficult or wordy lan­

6.

guage should be avoided.

10.

1994, 309:901-11.

Position of warnings counts. The top of major package

faces is the premier space on a package. This position

7.

sells cigarettes. Government should occupy it in the

Part I, 1 April 2000, p961.

Second-hand smoke (especially death from second­

hand smoke diseases) and addiction are two warnings

8.

hecs-sesc/tobacco/facts/surviving/index.html

fort.

In text-only warnings, white lettering on black back­

Health Canada. If I have lung cancer, what are my chances

of surviving? Available on-line at http://www.hc-scgc.ca/

themes that cause the tobacco industry special discom­

12.

Health Canada. Regulatory Impact Analysis Statement
(Tobacco Products Information Regulations). Canada Gazette

interests of public health.

11.

Doll R. et al. Mortality in relation to smoking: 40 years'

observation on mate British doctors. British Medical Journal,

9.

Buchan V. Ortho Pharmaceutical (Canada) Ltd, Ontario

ground, is more dramatic than the reverse, especially if

Court of Appeal, 17 January 1986, 54 Ontario Reports (2d):

it is framed with a white border. Attempts to camou­

92-123.

flage the text of messages in the colours of the pack­
age should be rejected.

10.

JTI-MacDonald Inc. c. Procureure Generale du Canada

(2002) C.S., p. 84, para. 473, p86, para484

13.

Deception undermines warning systems. Deceptive
claims or graphics should be banned (e.g. the light'

11.

and 'mild' family of descriptors).

14.

1994, 309:901-11.

Just as creativity with trademarks on packages is being
used by the industry, creativity should also be utilized

12.

with warning systems (e.g. surprise messages inside

Intergovernmental Negotiating Body on the WHO
Framework Convention on Tobacco Control. Draft WHO

the pack).

15.

Doll R. et al. Mortality in relation to smoking: 40 years'
observation on male British doctors. British Medical Journal,

framework convention on tobacco control. Geneva. Worid

Warnings should be rotated frequently. Wear-out of

Health Organization. 3 March 2003, Article II, 1(a).

messages should be prevented by scheduling regular

changes to the warning system.

13.

The 'light' and 'mild' consumer fraud. A brochure published

by the Non-Smokers' Rights Association and Smoking and

Health Action Foundation, December 2002, 8pp. Available
on-line at http://www.nsra-adnf.ca/DOCUMENTS/PDFs/

LightMildbrochure.pdf

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Acknowledgements

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41720738niw_labelstudy.pdf

15

Tools for Advancing Tobacco Control
in XXIst century:

Success stories and lessons learned

Outils pour poursuivre la lutte antitabac

au XXPsiecle:

Experiences concluantes
et nouveaux enseignements

WHO/NMH/TFI/FTC/03.1

pi i

Report on Smokefree Policies in Australia

Tobacco Free Initiative would like to thank
the Centers for Disease Control and Prevention (CDC), Atlanta, USA

for their generous support for this project.

© World Health Organization 2003
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The named authors alone are responsible for the views expressed in this publication.

Printed in World Health Organization, Geneva.

Report on Smoke-Free
Policies in Australia
Kerryn Riseley1
Senior Policy Officer

Alcohol, Tobacco and Koori Drug Policy Unit
Department of Human Services, Victoria

The views expressed in this report are those of the author

and do represent those of the Victorian Department
of Human Services

World Health Organization

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

WHO Regional Office for Africa (AFRO)

Cite du Djoue

Bolte postale 6

WHO Regional Office for Europe (EURO)

8, Scherfigsvej

DK-2100 Copenhagen

Brazzaville

Denmark

Congo

Telephone: +(45) 39 17 17 17

Telephone: +(1-321) 95 39 1OO/+242 839100

WHO Regional Office for the Americas / Pan
American Health Organization (AMRO/PAHO)

525, 23rd Street, N.W.
Washington, DC 20037

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World Health House, Indraprastha Estate
Mahatma Gandhi Road

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U.S.A.

India

Telephone: +1 (202) 974-3000

Telephone: +(91) 11 337 0804 or 11 337 8805

WHO Regional Office for the Eastern

WHO Regional Office for the Western Pacific

Mediterranean (EMRO)

(WPRO)

WHO Post Office

P.O. Box 2932

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1000 Manila

Library)

Philippines
Telephone: (00632) 528.80.01

Nasr City, Cairo 11371

Egypt
Telephone: +202 670 2535

Report on Smoke-Free Policies in Australia

Introduction

government buildings enjoys a high compliance rate, and a

smoke-free work environment is now an expected condition
Tobacco use is the leading cause of death and disease

of employment with the Government and, indeed, in many

in Australia. Each year nearly 20000 Australians die and

other professional settings.

more than 150000 are hospitalized due to tobacco-related

illnesses (1). The economic and social costs of tobacco
use in Australia are estimated at $AU 12,736.2 million per

annum (2).

However, smoking restrictions imposed by individual

employers and venue operators have failed to protect staff
and patrons in many enclosed environments, such as res­
taurants, pubs and casinos. A study conducted seven years

In 2001, approximately 22% of Australian adults were
smokers (3). Australian males (24.3%) are more likely to

prior to the introduction of smoke-free dining laws in New
South Wales found that not only did restaurateurs under­

smoke than Australian females (19.9%), with adult smok­

estimate patron demand for smoke-free areas, even those

ing rates peaking in the 20-29-year age group (4). Young

who did perceive the need to provide smoke-free areas

Australians are still taking up smoking at a disconcerting

offered few such areas (10).

rate, with 260000 students aged 12-17 estimated to be
smokers (5). Around one-third of 17-year-old students

Smoke-free legislation

smoke.
The responsibility for tobacco control in Australia rests

Smoking rates are significantly higher in some disadvan­

taged groups in the Australian community. People from

lower socioeconomic brackets, people with mental illnesses
and some ethnic communities such as Greek, Vietnamese

and Eastern Mediterranean, all have substantially higher

smoking rates than the general population (6,7,8). Of
particular concern is the smoking rate among indigenous
Australians, which is over double the rate of the over­

all Australian population: 53% of indigenous males and

primarily with state and territory governments. However,

the federal Government has played a leadership role, tak­
ing the country's first legislative step in this area by ban­

ning smoking on domestic airline flights in 1987. This was
followed by smoking bans in other federally controlled

areas, such as on interstate buses and coaches (1988), on
domestic sectors of international flights (1990) and on all

Australian airlines flights anywhere in the world and on all

international airlines flights within Australia (1996).

43.6% of indigenous females are smokers (9). While

smoking prevalence in the general Australian population is

As evidence mounted of the significant economic and

declining, there have not been corresponding decreases in

social costs of tobacco use in Australia, tobacco use

smoking prevalence in these high-risk groups.

was identified as a major public health issue, requiring a

coordinated national response. In 1994, the development

of a National Tobacco Strategy was endorsed by the

Smoke-free policies in Australia

nation's peak ministerial drug policy group, comprising
federal, state and territory health and law enforcement

Self regulation
As evidence has grown of the harmful impact of exposure
to environmental tobacco smoke (ETS), smoke-free envi­

ronments have become increasingly common in Australia.
Prior to introducing smoke-free legislation throughout

Australia's six states and two territories, self regulation

was the predominant means of regulating ETS exposure in
workplaces and public places, with employers and venue

ministers. The goal of the National Tobacco Strategy
1999-2003 is to improve "the health of all Australians
by eliminating or reducing their exposure to tobacco
in all its forms."2 Reducing exposure to ETS is a critical
part of the National Tobacco Strategy. The strategy is

informed by a set of guiding principles to assist states
and territories in implementing best practice smoke-free

legislation. Principal components of the guidelines are:

operators voluntarily implementing smoking restrictions at
premises within their control. In some areas, self-regulation

2

Commonwealth Department of Health and Aged Care.

has been highly successful. For example, a smoke-free work

National Tobacco Strategy 1999 to 2002-2003 A

environment policy was adopted throughout the Australian

Framework for Action. 1999, Canberra. Note that the

Public Service in 1988. This ban was the first of its type in

operation of the National Tobacco Strategy has been

Australia and similar policies were subsequently introduced

extended by 12 months to 2003-2004.

in public services across the country. The smoking ban in

0

0

World Health Organization

— non-smoking environments should be regarded as nor­

In the remaining jurisdictions, smoking in the workplace

mal practice in enclosed public places and workplaces;

is dealt with mainly under occupational health and safety

— there is no "right to smoke" in an enclosed public
place or workplace;

— smoking restrictions should apply equally to all premis­
es within any particular industry;

— any exempted premises must meet health-based crite­
ria for ETS; and

— compliance mechanisms should be based on education
and community support (11).

While no Australian jurisdiction has implemented smok­
ing bans as comprehensive as those recommended by the
guidelines, all states and territories have taken some leg­
islative steps to reduce ETS exposure in public places and

workplaces. South Australia and Victoria have adopted a
piecemeal approach, legislating to provide limited smoke-

free environments, such as restaurants, parts of licensed

premises and, in Victoria, shopping centres and gaming
and bingo venues.

Comprehensive legislation concerning smoke-free enclosed

legislation. In Western Australia, occupational health and
safety regulations prohibit smoking in the workplace,

although there are many exemptions, such as the allow­

ance of designated smoking areas. In the ACT, a Code

of Practice for Smoke-free Workplaces, which falls under
occupational health and safety legislation, recommends
implementing full smoking bans in workplaces. Failure
to comply with the Code of Practice may be used as evi­

dence in proceedings under the Territory’s occupational
health and safety legislation, but does not of itself consti­

tute a breach of the legislation. In the remaining states,

employee protection from ETS relies on general obligations
in occupational health and safety legislation that require

employers to provide a "working environment that is safe
and without risks to health."4 Attempts to use these gen­
eral obligations to ensure smoke-free workplaces, particu­

larly by workers and unions in the hospitality sector, have

proven largely unsuccessful. The National Occupational
Health and Safety Commission recently recommended
that ETS exposure be excluded, without exception, in

public places has been enacted in the Australian Capital

all Australian workplaces. However, state and territory

Territory (ACT) (1994), Western Australia (1999), New

Workplace Relations Ministers have not acted on this

South Wales (2000), Tasmania (2001), Queensland (2002)

issue, intimating that workplace exposure to ETS should be

and the Northern Territory (2003). A public place is

dealt with by Health Ministers through smoke-free legisla­

defined in similar terms in these jurisdictions. For example,

tion.

in the ACT it is defined as: "a place which the public, or a

section of the public, is entitled to use or which is open to,

or is being used by, the public or a section of the public

(whether on payment of money, by virtue of membership
of a body, or otherwise)."3 Places captured by this defini­

tion include enclosed restaurants, shopping centres, sport­
ing facilities, libraries, universities and public transport.

However, since many workplaces, such as factories are not

open to the general public, and employees are not con­

sidered to be 'a section of the public', legislative bans on
smoking in enclosed public places do not prohibit smoking
in all workplaces.

With smoke-free workplace legislation in place in only
three Australian jurisdictions, and even this legislation

failing to cover all workplaces, many Australian workers

remain at risk of ETS exposure. In the majority of work­
places, smoke-free policies are implemented at the discre­

tion of employers. A study of Victorian workplaces found
that around a quarter of workers had only partial or no
smoking restrictions in their workplaces and that 9% of

indoor workers in that state are potentially exposed to
tobacco smoke in their immediate work area (72). Blue-

collar workers and employees in the hospitality sector are
at highest risk of ETS exposure in the workplace (13, 14).

The Queensland legislation prohibits smoking in 'enclosed

Imposing full smoking bans in all enclosed workplaces is

places' and therefore covers workplaces as well as pub­

an initiative that is relatively inexpensive for governments,

lic places. Private places like residential premises, private

while having significant public health benefits (15).

vehicles and non-common areas of multi-unit residential

accommodation are specifically excluded from the ban.

3

Legislation in Tasmania (2001) and the Northern Territory

jurisdictions to include enclosed public places and enclosed
workplaces. However, regulations in the Northern Territory
4

permit employers to designate smoking areas.

Section 2, Smoke-free Areas (Enclosed Public Places) Act
1994 ACT.

(2003) creates 'smoke-free areas' that are defined in both
4

For example, section 21 of the Occupational Health and

Safety Act 1985 (Victoria).

Report on Smoke-Free Policies in Australia

Exemptions from smoke-free laws

0

Hospitality industry groups have actively opposed imple­

menting smoke-free laws on the basis of their negative
Despite the existence of comprehensive smoke-free public

economic impact on hospitality businesses, an argument

places legislation in the majority of Australian jurisdictions,

that is contrary to both Australian and international

smoking is still generally permitted in licensed venues (that

research findings (18). The AHA has been particularly

is, hotels, pubs, bars and clubs), casinos and gaming areas,

active in advocating an accommodation model using ven­

with these venues either wholly or partially exempted from

tilation and segregation of smokers and non-smokers as

smoking bans. The application of smoking restrictions to

an alternative to legislative bans. The AHA’s draft accom­

licensed premises differs in each jurisdiction, and is invari­

modation code is modelled on the United Kingdom's

ably complex. Exemptions from smoking bans apply, for

AIR Initiative, which receives funding from the Tobacco

example, to single-room premises (Victoria), to bar areas

Manufacturers Association (19). Also of concern is the

(New South Wales, Tasmania and Queensland), to enter­

claim by unions in New South Wales that the extension

tainment areas (South Australia), to places with adequate

of smoking bans in that state has been slowed by political

ventilation (Western Australia and ACT) and to places with

donations by members of the hospitality industry (20).

ministerial exemptions (ACT and South Australia).

In jurisdictions where there is no comprehensive smokeThe Tasmanian legislation provides that a 'reasonable area’

free legislation, or where gaps in the law exist, smoking

of a bar area must be smoke-free and stipulates that the

policies voluntarily adopted by venues or organizations

smoke-free area must not be of ’inferior amenity’ to the

continue to play an important role. Often such policies

smoking area. The legislation does not define ’reason­

are motivated by the threat of litigation as well as patron

able area’ or 'inferior amenity’ and a current review of

and staff demand. For example, while Western Australia’s

that legislation has identified this as a significant area of

Burswood Casino is specifically exempted from the

confusion for both patrons and venue operators (16). In

smoke-free regulations in that state, intense lobbying and

the Northern Territory, occupiers of licensed venues may

union pressure led to the venue introducing a smoke-free

designate smoking areas, as long as a smoke-free area

policy. In New South Wales, a draft agreement between

of ’equal amenity’ is maintained. An attempt is being

Government, publicans, the casino and workers provides

made to define 'equal amenity’ through an industry code

that all licensed premises will be 'predominantly smoke-

that is currently being drafted by the Australian Hotels

free’ by 2005 (21). What this means and how it will be

Association (AHA) in consultation with the territory gov­

achieved is still being negotiated.

ernment (17).

While best-practice smoke-free legislation would cover

all public places, including licensed premises, casinos and

gaming venues, to date no Australian jurisdiction has

Implementation model:
the introduction of smoke-free
dining in Victoria

committed to making these venues totally smoke-free.
Hospitality industry groups, many of which have close ties

The effective implementation of smoke-free policies relies

to the tobacco industry, have played a significant role in

on a number of key elements such as consultation and

ensuring the continuing exemption of licensed premises,

education. The policy development and implementa­

gaming areas and casinos from smoke-free legislation

tion process is discussed below in relation to introduc­

across the country. For example, both Philip Morris and

ing smoke-free dining laws in Victoria from 1 July 2001.

British American Tobacco Australiasia provided funding to

Similar implementation models have been used when

the Tasmanian branch of the AHA to assist in preparing

introducing smoke-free laws in other jurisdictions such as

materials to lobby Parliamentarians prior to introducing

Queensland (2002) and the Northern Territory (2003).

smoke-free laws in that state.5

In the late 1990s Victoria was lagging behind other
Australian jurisdictions in providing smoke-free environ­

ments. In 1999, a new state government came to office

with the expressed policy commitment of protecting the
5 Edwards C. Hansard, Parliament of Tasmania. 29 March
2001.

Victorian community from the harms of ETS exposure.

In developing its smoke-free dining laws, the Victorian
Department of Human Services undertook extensive

5

World Health Organization

consultations with stakeholders, including other relevant

— the publication of a comprehensive booklet explain­

government departments (for example, the Treasury and

ing the laws and how to comply with them (28). The

small business), regulatory authorities (for example, Liquor

booklet and free signage was mailed to Victoria's 16

Licensing Victoria), industry groups, key employers, unions

400 eating establishments. It was printed in seven

and health bodies. The input of these groups helped to

community languages to meet the diverse language

inform policy development, in particular how the smoking

bans would apply to licensed premises with a dining com­
ponent, such as pubs.

Restaurateurs voiced concerns about the potential nega­
tive impact of smoke-free dining and were particularly

critical of the fact that the bans singled out the restaurant

industry, with smoking still permitted in other venues
such as bars and gaming venues, a distinction that is not
justifiable on health grounds (22,23,24). As has been the

experience in other jurisdictions, the tobacco industry was

needs of Victoria's multicultural community.

— education seminars for restaurateurs conducted
throughout the state, including in rural areas. A total

of 650 people attended 18 seminars held at 9 different
locations.

— community and industry radio and press advertis­
ing campaign (in both mainstream and multicultural
media).

— workshops to educate enforcement officers about the

active in rallying restaurant industry opposition to the ban.

new laws. A total of 245 enforcement officers from the

Tobacco industry documents show that Philip Morris was

state's 78 local councils attended these workshops. The

heavily involved in a lengthy campaign run by 50 of the

government of Victoria provided $AU 1.3 million to

state's top restaurants to win community support for an

councils to undertake education visits to eating estab­

accommodation model, rather than a legislated smoking

lishments to ensure awareness and compliance with

ban (25). However, as will be discussed in more detail

the new laws.

later in this report, several other Australian jurisdictions
had already introduced smoke-free dining without nega­

tive consequences for business and surveys showed that
the Victorian public was highly supportive of the proposed

new laws (26). This, coupled with strong support from
key health and union groups, ensured the successful pas­

sage of smoke-free dining legislation through the Victorian

— telephone information line and web site (29). Both the
web site and phone line were well utilized. There were

1475 hits to the web site in June 2001, the month
prior to the introduction of smoke-free dining, and 2
075 hits in July 2001. Nearly 1000 calls were made to

the phone line in both June and July 2001.

Parliament in 1999 with bipartisan support.

The success of the communications campaign was dem­
The Victorian state government conducted an AUS

onstrated by pre- and post campaign surveys, which

500,000 communications campaign to inform both indus­

were conducted to assess awareness of smoke-free dining

try members and the community about the new laws (27).

among eating establishment proprietors (30,31). Of the

A key component of the laws' successful implementation

eating establishment proprietors surveyed three weeks

was the input and support of industry groups and mem­

after the introduction of smoke-free dining, 100% were

bers. An advisory committee comprising key employers,

aware of the laws, compared with 80% of those in the

industry groups, health bodies, unions, enforcement offic­

pre-campaign survey. The relatively high rate of pre­

ers and other key government departments was estab­

campaign awareness can be attributed to heavy media

lished to advise on the communication needs of stakehold­

coverage of the smoke-free dining laws and the active

ers. As well as providing advice on the advertising cam­

role played by industry groups in providing information on

paign and signage, the members of this group also played

the laws to members. Importantly, the communications

an important role in disseminating information on the laws

campaign was shown to have been significant in increas­

through industry seminars and newsletters. One vital func­

ing proprietors' understanding of the details of the law,

tion of this group was to provide feedback on potential

such as the requirements to display signage and not to

implementation issues, enabling these to be addressed at

provide ashtrays as well as the offences under the legisla­

an early stage.

tion. Awareness of such details increased by an average of

87% among restaurant proprietors and 77% among hotel
Other key communications campaign elements included:

and club proprietors between the pre- and post campaign

surveys. Over three-quarters of proprietors surveyed rated

Report on Smoke-Free Policies in Australia

the mailed government information as helpful or very
helpful in assisting them to implement smoke-free dining.

It should be noted that while the major costs of imple­
menting smoke-free laws are associated with the initial

public awareness campaign, there are some ongoing costs
to the Government, including the maintenance of a web

site and telephone information line, provision of signs as

well as continuing education and possible low-level fund­
ing of enforcement officers.

Measuring the success of Australia's
smoke-free policies

some cases, enforcement officers, have had difficulty in

applying smoking restrictions, which are based on subjec­
tive criteria such as the 'predominant activity of an area',

whether meals (as opposed 'snacks') are being served and
whether an area is ‘substantially enclosed’. The experi­
ence in these states demonstrates the importance of well-

drafted, easy-to-apply legislation. It also highlights the
necessity of providing ongoing assistance to proprietors,
such as education visits by enforcement officers and the
maintenance of a telephone information line.

As compliance with the smoke-free laws is high, enforce­

ment officers primarily respond to complaints rather than
conducting active compliance monitoring. Enforcement

The success of smoke-free laws across Australia is demon­

is undertaken by a range of personnel across the coun­

strated by widespread compliance, high levels of commu­

try, including local council officers (e.g. in Victoria), area

nity support and a decrease in tobacco consumption.
Compliance

The experience in all Australian jurisdictions has been that

health staff (e.g. in New South Wales), police (Northern

Territory), licensing officers (Northern Territory) and volun­
teers (Tasmania). Some jurisdictions, such as the Northern

Territory and Queensland, have on-the-spot fines

smoke-free laws are generally self-enforcing, with smok­

(infringement notices) while in the majority of jurisdic­

ers refraining from smoking in smoke-free areas once they

tions, enforcement is by way of prosecution. In all jurisdic­

become aware of the laws. Following the introduction of

tions there are penalties for occupiers who fail to display

smoke-free dining in South Australia, venue owners and

prescribed signage (SAU 75-100 infringement notice or

managers were surveyed in relation to customer compli­

$AU 500-5,000 fine) or who allow smoking in a smoke-

ance with the laws (32). Five months after the commence­

free area (SAU 100-150 infringement notice or SAU

ment of the laws, 93.8% reported observing either no or

500-11,000 fine). Occupiers are defined in similar terms

few customer breaches of the smoking ban. This reported

in most jurisdictions as the person managing, controlling

compliance rate increased to 95.5% after 18 months.

or in charge of an enclosed place or part of an enclosed

Where a breach of the legislation was observed, most

place. Individuals who smoke in a smoke-free areas may

proprietors reported asking the smoker to cease smoking,

also receive a SAU 75-150 infringement notice or a SAU

with only 4.4% of customers refusing to comply with this

500-2,200 fine. In practice, however, most complaints

request. These findings are consistent with a survey of din­

result in the provision of education and the clarification of

ers in that State in which only 1.8% of smokers reported

the law rather than any punitive enforcement action.

smoking in a non-smoking dining area (33). Similar highcustomer compliance rates have been reported in other

jurisdictions (34).
A compliance inspection of South Australian eating estab­
lishments found that venue compliance with the legislation
was between 88.2% and 92.3% five months after the

introduction of smoke-free dining and between 95.7%
and 99.6% after 18 months (35). While only 1 % of

premises were found to be breaching the laws by allowing

smoking indoors, one-third of premises were not display­
ing the prescribed signage.

Community support
Smoke-free environments have been well received by the

Australian community. A survey of community attitudes
towards South Australia's smoke-free dining laws found that
support for the laws was high, increasing from 81 % four

months after the laws' implementation, to 85% after 18

months (38). Smokers were less likely than non-smokers to
support the laws, but smoker support also increased from

54.8% after four months to 61 % after 18 months. Patrons
reported increased enjoyment of dining out and were also

Reviews of smoke-free legislation currently underway in

found to be slightly more likely to dine out following the

Tasmania and Western Australia, both identify proprietor

introduction of the smoke-free dining laws. Of the smokers,

confusion as a barrier to compliance with smoking restric­

80.7% reported that smoke-free dining laws had not affect­

tions (36, 37). Both reviews note that proprietors and, in

ed their dining habits. These findings of high community

Report on Smoke-Free Policies in Australia

e Awstralian Bureau of Statistics' Retail Trade

3.

persons aged over 18 years, excluding CATI.

thaat introducing smoke-free dining in South

19999 did not have an impact on the ratio of

Australian Institute of Health and Welfare. National Drug

Strategy Household Survey 2001. 2002, Canberra, Data for

ales data over the period 1991-2001, the

4.

jrnoover to retail turnover in that State. In addi-

Australian Institute of Health and Welfare. National Drug
Strategy Household Survey 2001. 2002, Canberra. Data for

idy found that there was no decline in the ratio

persons aged over 18 years, excluding CATI.

istraalian restaurant turnover to the restaurant
the: Australian states that had not introduced

5.

dinning at that time.

Prevalence Study and Comparisons with Earlier Years.

f siubjective studies, based on proprietors' and

Australian and New Zealand Journal of Public Health, 2002,

)re:ssions of the impact of smoke-free laws

26:2: 156-163.

®m undertaken (54). These studies have also

igjly found that smoke-free policies do not

Hill D, White V, Effendi Y. Changes in the Use of Tobacco
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6.

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Department of Human Services, Victoria. Guess What’s

174:512-515.
40.

and Research Report No 5, 1995-1998. 1999, SASHP,

accessed at: www.tobaccoreforms.vic.gov.au.

30.

www.tobaccoreforms.vicgov.au.

Adelaide.

41.

from the April (2001 & 2002) Smoking and Dining Crosssectional Survey. 2002, Cancer Council, Victoria, Melbourne.
42.

10

Miller C, Kriven S. Smoke-free Dining in South Australia:

Surveys of Venue Managers and Inspections of Premises

Makkai T, McAllister I. Public Opinion Towards Drug
Policies in Australia 1985-95. 1998 Department of Health

Department of Human Services, Victoria. Awareness and

and Family Services, Canberra.

Perception of Smokefree Dining. 1 August 2001, Melbourne.

32.

Centre for Behavioural Research in Cancer. Top Line Results

Department of Human Services, Victoria. Awareness

and Perception of Smokefree Dining. 20 March 2001,

Melbourne.
31.

Wakefield M, Roberts L and Owen K. Population Monitoring

of Tobacco Control Progress in South Australia. Evaluation

Not on the Menu. 2001, Melbourne. This booklet can be

29.

Chapman S, Borland R, Lal A Has the Ban on Smoking in
New South Wales Worked? A Comparison of Restaurants

Help Stamp out Smoking. 12 October 2000, Melbourne.
28.

Miller C, Kriven S. Smoke-free Dining in South Australia:

Surveys of Community Attitudes and Practices after 4 and

Sun, Melbourne, 12 May 2000, p7.

43.

Wakefield M et al. Effect of Restrictions on Smoking at

Home, at School, and in Public Places on Teenage Smoking:

Report on Smoke-Free Policies in Australia

Cross Sectional Study. British Medical Journal, 2000, 312:

333-337.
44.

Trotter L, Wakefield M, Borland R. Socially Cued Smoking
in Bars, Nightclubs, and Gaming Venues: a Case for

Introducing Smoke-free Policies. Tobacco Control, 2002, 11:

300-304.
45.

Chapman S et al. The Impact of Smoke-Free Workplaces

on Declining Cigarette Consumption in Australia and the
United States. American Journal of Public Health, 1999, 89:

7:1018-1023.

46.

Farkas A et al. The Effects of Household and Workplace

Smoking Restrictions on Quitting Behaviours. Tobacco
Control, 1999 8:216-5.
47.

Miller C, Kriven S. Smoke-free Dining in South Australia:

Surveys of Venue Managers and Inspections of Premises
after 5 and 18 Months. Tobacco Control Research and

Evaluation Report, 1998-2001 Volume 1, 2002. Tobacco
Control Research Evaluation Unit, Adelaide.

48.

Broadbent C, Wesley S. Ventilation Issues and Risk from
Exposure to Environmental Tobacco Smoke. Passive Smoking

in the Hospitality Industry - Options for Control, 1997, New

South Wales Passive Smoking Taskforce, Sydney.
49.

National Public Health Partnership National Response to
Passive Smoking in Enclosed Public Places and Workplaces
Background Paper. November 2000, Canberra.

50.

Bartoch W, Pope G. The Economic Effect of Smoke-Free
Restaurant Polices on Restaurant Business in Massachusetts.
Journal Public Health Management Practices, 1999, 5:63-73.

51.

Hyland A, Cummings K. Restaurateur Reports of the
Economic Impact of the New York City Smoke-Free Air Act.
Journal Public Health Management Practices, 1999, 5:37-42.

52.

Scollo M, Lal A. Summary of Studies Assessing the Economic

Impact of Smoke-Free Policies in the Hospitality Industry
- includes studies produced to December 2002. VicHealth
Centre for Tobacco Control, Melbourne, www.vctc.org.au/

tc-res/Hospitalitysummary.pdf. Accessed 14 February 2003.
53.

Wakefield M et al. The Effect of a Smoke-free Law on

Restaurant Business in South Australia. Australian and New
Zealand Journal of Public Health, 2002, 26:4 375-380.

54.

Markham V, Toong R. Reactions and Attitudes to Health
(Smoking in Enclosed Places) Regulations 1999, 2001,

www.acosh.org/library_fr_set.htm. Accessed 11 November

2002.

55. Chapman S, Borland R, Lal A. Has the Ban on Smoking in

New South Wales Worked? A Comparison of Restaurants
in Sydney and Melbourne. Medical Journal Australia, 2001,

174: 512-515.

Tools for Advancing Tobacco Control

in XXIst century:

Success stories and lessons learned

Outils pour poursuivre la lutte antitabac

au XXPsiecle:

Experiences concluantes
et nouveaux enseignements

Effective Act
obacco
Dependence
Treatment

Tobacco Dependence Treatment in England

3

Tobacco Free Initiative would like to thank
the Centers for Disease Control and Prevention (CDC), Atlanta, USA
for their generous support for this project.

© World Health Organization 2003

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Printed in World Health Organization. Geneva.

Tobacco Dependence
Treatment in England
Martin Rawa,
Ann McNeilP
a Freelance consultant,

Honorary Senior Lecturer,
Department of Public Health Science,

Guy's, Kings and St Thomas'
School of Medicine,
University of London.
b Freelance consultant, Honorary Senior

Lecturer, Department of Psychology,
St George's Hospital Medical School,
University of London.

World Health Organization

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

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Telephone: +202 670 2535

Tobacco Dependence Treatment in England

Introduction

Figure 1
Adult smoking prevalence in England (per 100)

In England' (as in the United Kingdom of Great Britain and
Northern Ireland as a whole) smoking prevalence in adults
(aged 16 and over) has been falling in both men and

women since the 1970s (1). During the 1990s, however,

this decline levelled off, as the diagram below illustrates.
Currently, in England 27% of adults smoke - 28% of men

and 26% of women. Over the last 20 years there has
been a similar trend in 11-15-year-olds, in whom preva­

lence has fallen only very slightly. In 1982, 11% of 11-15-

year-olds were regular smokers (defined as at least one
cigarette a week on average), 11 % of boys and 11 % of

girls. In 1999, the figures were 9%-8% of boys and 10%

of girls (1).
There are currently about 13 million smokers in Britain (2)
and a large socioeconomic gradient: 15% of professionals

smoke compared with 39% of unskilled manual workers

years (5). The total annual cost of smoking-related disease

(1). This gradient has become steeper as more profession­

to the national health service (NHS) in England is from

als have stopped smoking. There is also evidence of higher

about £1,500 to £1,700 million a year (about US$ 2,250

dependence within the more deprived smokers (3). Most

to USS 2,550 million; all dollar conversions at £1 = SUS

smokers (82%) start as teenagers and most - about 70%

1.5) (6).

in Britain (see footnote) - say they want to stop (1). Even

among those who want to stop, the unaided cessation
rate measured at one year is less than 5% (4).

In the United Kingdom of Great Britain and Northern
Ireland more than 120000 people a year are killed as a

The historical context: development
of policy on tobacco control and on
treatment within it
The development of a policy to treat dependent smok­

result of smoking, mainly through lung cancer, chronic

ers in the United Kingdom should be seen in the context

obstructive pulmonary disease and coronary heart disease.

of the development of tobacco control as a whole, which

This represents one in five of all deaths (1.2). Half of all

was a lengthy process. Doll & Hill's first report, in 1950,

lifelong smokers are killed by their smoking in middle age

linking the increase in lung cancer to smoking (7), planted

(35 to 69 years), and the average loss of life is 15 to 20

the seed. Their work led to the establishment of the British

doctors’ study, a long-term cohort study that is still yield­
The data and events described in this paper are from

ing data now on smoking death rates. In 1962, Charles

England unless otherwise stated. Government policy on

Fletcher persuaded the Royal College of Physicians (RCP)

smoking, and its 1998 White Paper (2) apply to the whole

to publish their first report on smoking and health (8), and

of the United Kingdom of Great Britain and Northern

this was really the beginning of the tobacco control cam­

Ireland (England, Scotland and Wales and Northern

paign in Britain. Disappointed by the lack of political action

Ireland) have implemented a broadly similar policy on

following the report's publication, the college published a

treatment for smokers. However, the countries have

second report in 1971 (9) and, perhaps more significantly,

slightly different healthcare systems and the authors' main

created the organization Action on Smoking and Health

experience and involvement has been in England, so this

(ASH), which appointed its first campaigning director

article has focused on the situation in there. This is also

in 1973. The Government set up the Health Education

why over the years survey data have not consistently been

Council (later called the Health Education Authority (HEA),

available for one country and so have sometimes been

then the Health Development Agency) in 1967, so that

drawn from England, and sometimes from Britain and the

by the mid-1970s, a decade after the first RCP report,

United Kingdom.

there were governmental and nongovernmental bodies
campaigning on smoking and health. However, progress

3

World Health Organization

was slow. In 1984 the British Medical Association (BMA),

progress over several decades of a team of researchers,

which represents about 90% of all British doctors, added

which resulted in pioneering research on nicotine addic­

its influential voice to the campaign (10). During the

tion, the role of the general practitioner (12), behavioural

1980s, one of the main focuses of the campaign was an

treatment and groups, and nicotine replacement therapy

advertising ban. This was unsuccessful but during this peri­

(13), inter alia. Furthermore, many of the group, led by

od governments started using increases in taxation to raise

Michael Russell, remained in the field after leaving the

revenue, and later (explicitly) to reduce smoking preva­

Addiction Research Unit and contributed to the continu­

lence. It could be said that by the 1990s, 30 years after

ing evolution of treatment policy and research, from uni­

the campaign began, the Government officially accepted

versities, the health service, and a national governmental

the harm caused by smoking and the goal of minimizing
this harm. Also during the 1990s an increasing role was
being played by the HEA, which built up and contributed

to expertise in tobacco control.
While extremely important, none of these developments

organization.

Thus, by the mid-1990s, in Britain there was a strong

tobacco control coalition. It was led (informally) by the
campaigning organization ASH, supported by exper­

tise from the HEA (that funded supporting projects and

in itself directly advanced the case of treating tobacco

research), which included medical and other health pro­

dependence. Tobacco dependence was not widely recog­

fessionals, and university-based treatment specialists and

nized as an addiction until the 1990s (the United States

researchers developing the evidence foundation. The

Surgeon General's report on nicotine addiction was pub­

ground was fertile. All these strands were brought togeth­

lished in 1988 (11)). Some in the health education field in

er following the election in 1997 of a new Government,

Britain felt it was more important to concentrate resources

which promised concerted action against tobacco, includ­

on mass population approaches to persuading smokers to

ing an advertising ban and a tobacco "White Paper" - a

stop, rather than on a minority of nicotine addicts who

formal Government policy paper (2).

needed help. In effect, smoking was seen as an educa­

tional issue, the key task being to persuade smokers that
they should try to stop. Such mass population approaches

are important. Because of their wide reach they can trig­
ger quit attempts, and cessation, on a massive scale. They

are also an important precursor to helping smokers stop
since they create the demand for this help, by increasing
motivation to stop. Treatment services are unlikely to be
feasible in a country that does not have a broader tobacco

During 1997, while the Government was writing the
White Paper, the HEA commissioned the first English
smoking-cessation guidelines. These guidelines played a

large part in shaping Government policy as a result of the

interaction among the cessation researchers writing them,
the HEA director who managed the project and a key offi­

cial in the Department of Health. New treatment services
were written into the White Paper.

control campaign, since there may not be enough smok­

Three key concepts were also vital in persuading the

ers motivated to stop. By the same token, once there is

Government of the importance and value of treatment to

greater motivation to stop smoking in a population, it then

help dependent smokers stop: that smoking is an addic­

becomes clear that many smokers are addicted to nicotine

tion (4), (11), (14),(15), that treatment is effective (16),

and need help in stopping. The statistics quoted above

(17), and that treatment is cost effective (6). It was impor­

remind us of this: about 70% of smokers in England want

tant to emphasize that many smokers are nicotine addicts

to stop, and the unaided cessation rate is less than 5%.

who need and deserve help from the health care system.

This fact is underscored by the classification of nicotine

It was during the 1990s in Britain that treatment of

addiction/tobacco dependence as a disease by the World

dependent smokers finally became accepted as an

Health Organization's ICD classification (14) and by the

important activity in its own right. One occurrence that

American Psychiatric Association's DSM-IV classification

influenced this was the parallel development of research

(15). Within Britain, the Royal College of Physicians report

on tobacco addiction, the best-known national centre

Nicotine Addiction in Britain (4) was significant, again illus­

in Britain being the Addiction Research Unit in London,

trating how influential medical professional bodies can be.

part of London University, which during the 1970s and

1980s was supported by large programme grants from

The effectiveness and cost-effectiveness evidence were

the Medical Research Council. The relatively long dura­

also important in demonstrating that money spent by the

tion of the funding was important, because it allowed the

health care system helping smokers stop is extremely well

Tobacco Dependence Treatment in England

spent. When the national cessation guidelines were first

treatment services. The new treatment services were to be

published, guidance on cost effectiveness was published

developed over three years starting in April 1999. In the

with them. This guidance showed smoking cessation to

first year, £10 million (USS 15 million) would be spent in

be one of the most cost-effective interventions in the

26 selected "pilot" areas; areas especially chosen for their

health care system. It produces one extra life year at a

levels of social and economic deprivation. In April 2000

cost of less than £1,000, compared with an average cost

the services were extended to the rest of England, with a

of £17,000 from a review of 310 medical interventions

budget of up to £20 million (USS 30 million) for the first

(6). These data and arguments compelled key people,

year, and up to £30 million (USS 45 million) for the sec­

including those inside Government, to support a treatment

ond year. At the time it was not stated by the Government

policy. Since the treatment services were established, a

what would happen to the services when the funding ran

new Government body, the National Institute of Clinical

out in March 2002. Services were advised to target prior­

Excellence (NICE), has published its own assessment of the

ity groups, in particular socially disadvantaged smokers.

effectiveness and cost effectiveness of NRT and bupro­

In addition, in each year targets were set for the numbers

pion, which has added strong and authoritative support to

of smokers who had received specialist support though

the services (18).

the services and reported having stopped four weeks after

The provision of new funding (see next section) - for edu­
cational measures and separately for treatment services

- was fundamental in advancing the case of treatment.

It had been argued in the past that scarce health educa­

their quit date. Because these targets were exceeded in
years one and two, they were increased for the third year
of services, and again for the (subsequently funded) fourth

year.

tion resources should not be 'diverted' from population

Implementation of the new policy developed as more

approaches to treatment, which would not affect popula­

detailed guidance was provided by the Government and as

tion prevalence. The new funding meant that educational

problems were encountered. One problem that had nega­

approaches could continue, and that treatment could be

tive consequences throughout the project was the short­

offered by the appropriate sector - the healthcare system

term nature of the funding. Originally, the Government

(as opposed to the health education sector).

said that money for year two would depend on evidence

Thus, after years of failing to recognize the needs of

of success from year one (2) - an unrealistically short time

addicted smokers, a policy on treatment emerged within

scale in the real world. In the third year of the project a

a wider tobacco control policy drawn up officially by the

lobbying campaign was launched to try to persuade the

Government. The Government White Paper also crucially

Government to announce further funding to continue the

proposed a tobacco advertising ban, action on tobacco

services, in order to prevent staff losses caused by short­

taxation, smoking in public places, under-aged smok­

term contracts (19). This campaign included a document

ing, smoking and pregnancy, and action against cigarette

written by experts and supported by professional bodies,

smuggling.

the Department of Health, and the pharmaceutical compa­

Chronology and implementation of new
English treatment policy

that could be made on other aspects of the health care

nies, setting out the cost-effectiveness argument for treat­

The Government's White Paper Smoking Kills was pub­

lished in December 1998 (2). English national smoking
cessation guidelines (16), along with guidance on cost

effectiveness (6), were also published by the HEA, for the
first time ever, in December 1998 and launched by the

Public Health Minister in 1999. These guidelines were
evidence based and formally endorsed by more than 20

ing smokers (20). This document illustrated the savings

system, such as statins (cholesterol-lowering drugs that
reduce the risk of heart disease) expenditure, if smoking

cessation interventions were a routine part of health care.
It was produced with the support of the World Health

Organization (WHO) Europe Partnership Project (21). At
the end of 2002 one year's extra funding - the fourth year

- was announced, thus extending the project to March
2003.

professional organizations, including medical and nursing

Despite the formidable challenge of setting up a brand

bodies. The Minister announced that approximately £110

new treatment service nation-wide, progress was rapid.

million (about USS 165 million) would be made available

By the end of 1999, just 9 months after the official start

for tobacco control in England, roughly half of this for new

of the new services, 137 new staff (mainly cessation

5

World Health Organization

counsellors but also managers - many of whom were also

free to those smokers least able to afford it, who were

cessation counsellors) in England were already in post.

attending the services. This was done through a voucher

This was a remarkable achievement in such a short time,

scheme, which was criticized because of the time and

considering the need to move the money to the health

resources needed to implement it, but also because while

service, advertise for new staff, appoint them, and train

it was a modest step forward, it was less than justified on

them. At the time of this writing (late 2002) the services

clinical and cost-effectiveness grounds. It ignored the fact

have some 500 paid staff, with many more primary care

that most smokers do not use enough NRT and for long

professionals who have been trained to give smokers sup­

enough when they attempt to quit. Lobbying for proper

port as part of their wider work.

reimbursement therefore intensified, led by ASH (23).

The Government spent £53 million (JUS 80 million) on the

Bupropion is an anti-depressant that has been on the

new services in their first three years (this does not include

market in the United States of America for over ten years,

expenditure on pharmaceuticals) and up to £20 million

and was discovered serendipitously to increase cessation

(SUS 30 million) more in the fourth year, which is still in

in smokers. Thus, it is an entirely different class of drug

progress at the time of this writing (22).

from NRT. When it was introduced in the United Kingdom

A crucial part of the smoking cessation services was the
offer of effective pharmacotherapies. The evidence shows

that in any setting pharmaceutical treatment (nicotine

replacement therapy and/or bupropion) approximately
doubles success rates (16), (17). The chronology of policies

on these medications is outlined below.

in June 2000, it was made available on NHS prescription,

creating a disparity between the way two effective smok­
ing cessation pharmacotherapies were treated. This had

a disruptive effect on the treatment services. Finally, in
April 2001, almost 20 years after it was first licensed for
use in England, NRT was also made available on reimburs­
able NHS prescriptions. This is crucial for poorer smokers.

Although there is a prescription charge for those who can
Smoking cessation pharmacotherapies

afford it (about £6 or JUS 9.00) almost 80% of all pre­

Nicotine replacement therapies (NRTs) had been licensed

scriptions are free to users, usually because of their eco­

in England since 1982, when nicotine gum was intro­

duced as a prescription-only medicine. Unfortunately, the
Advisory Committee on Borderline Substances at the time

nomic status. This means that, in effect, making NRT and

bupropion available on NHS prescription makes it free to
smokers who would otherwise have difficulty affording it.

decided that the gum was a "borderline substance" (not a

In 1999, the 2-milligram gum was given a general sale

truly medicinal product with clinical or therapeutic value),

license, meaning it also became available in non-pharmacy

which meant that the gum should not be available on

outlets like shops, supermarkets and petrol stations. This

reimbursable NHS prescriptions. Only private prescriptions

had been advocated by many health organizations (4), to

were therefore allowed (in which the patient pays the full

enable cost-effective treatments to be as accessible and

price apart from Value Added Tax). When 'blacklisting'

available as cigarettes. In May 2001, other NRT products

(when the Government blacklists a medicine it specifi­

were added to the general sale list.

cally excludes it from being prescribed on the NHS) was
introduced, the nicotine gum was automatically added

to it. In 1991, the gum became available in pharmacies
over-the-counter (OTC). As the newer NRT products were
introduced to the market they continued to be 'blacklisted'
and although the criteria changed slightly, they were

still not considered a priority for the use of limited NHS
resources (23). Researchers and practitioners advocated

strongly that NRT should be available on the NHS; indeed,

this had been advocated for almost 20 years (24). Most

of the other NRT products also became available through

pharmacies.
The White Paper acknowledged the effectiveness of NRT

but only allowed one week's supply of NRT to be given

In summary, in the United Kingdom there are currently

two types of pharmaceutical smoking cessation treatments
(and seven products) available: nicotine gum, the nicotine

patch, the nicotine inhalator, nicotine nasal spray, nicotine
lozenge, nicotine sub-lingual tablet, and bupropion. Some
are available through three routes (NHS prescription, from
a pharmacist (OTC), general sale, e.g. supermarket) but

bupropion is prescription only:

_

All of them are now available through the NHS on pre­
scription.

— All NRTs are available in pharmacies, where they can
be bought under the supervision of a pharmacist

(OTC).

Tobacco Dependence Treatment in England

— Some NRTs are also available on general sale, which

means any shop can sell them: 2-milligram and 4-mil-

Smokers are encouraged to take advantage of the behav­
ioural support offered. This maximizes cessation rates and

ligram gum, all the patches, and the 1-milligram loz­

means higher success rates than would be achieved if they

enge.

only used pharmaceutical products. Thus, at the heart of

Thus since 1998 and the launch of the Government's

smoking cessation services, there have been several

significant policy changes regarding smoking cessation
medications. While these were warmly welcomed from

the system is behavioural support, in groups or individual,
which typically consists of support, teaching coping strate­

gies and providing encouragement and help in the use of

smoking cessation pharmacotherapies.

the tobacco control community, the piecemeal nature of

One of the original rationales for treatment guidelines and

their introduction created difficulties for those running the

for the services proposed by them, was to engage the

services.

entire health care system in treating addicted smokers, by
ensuring that when general practitioners raise the issue

Description of treatment services in
England

and advise smokers to stop, they can refer them to spe­
cialist treatment. In effect, the idea was to make tobacco

dependence treatment like the treatment of any other

At the time of this writing, in late 2002, every health

condition in the NHS: primary care acts as initial point of

authority in the country offers treatment to dependent

contact and advice (it has been called the gatekeeper role)

smokers who want help in stopping through the National

and then refers to specialist treatment when necessary. In

Health Service. This means that the treatment is free to all

Britain this had been true for many years for those addict­

users (although partial payment can be required for the

ed to illicit drugs and to alcohol, but nicotine addicts were

pharmacotherapies as described above). Each local service

excluded from such help.

has a coordinator, whose role is that of service manager,

although many of them also do some cessation counsel­

A key role of the smoking cessation coordinator was

ling. Under them the coordinator has counsellors trained

therefore to promote the services to primary care staff

and paid to help smokers stop, and most services have

(particularly general practitioners) and to offer training

also trained primary care nurses (and others like pharma­

and support to these healthcare professionals. Involving

cists) to include counselling of smokers within their wider

general practitioners and other primary care staff in the

work.

treatment of nicotine dependence is important for two

Exact service models vary according to local conditions,

ers, and although only a small percentage will stop as a

reasons. First, this advice triggers quit attempts in smok­
especially depending on population spread. However, in

result, this is an important effect since general practitioners

its official guidance on how to set up the services, the

can reach so many more smokers than could be reached

Government urged the services to base themselves on

through intensive support alone (25), (26), (27). Secondly,

the evidence base which, inter alia, meant they should

although smokers can self-refer to the services, a greater

not offer treatments that do not work. One model, found

throughput will be achieved if general practitioners and

more in cities, has a core central clinic where special­

other primary care staff also refer or recommend smokers

ist counsellors run groups that offer behavioural support

to the services.

plus pharmaceutical aids, with satellite clinics also offering
groups run in the community. This central service trains

This model of care is now beginning to be achieved but a

and supports community counsellors, often nurses, who

few cautionary statements are in order. First, when NRT

offer smokers support usually in primary care settings.

and bupropion could be prescribed, it became easier to

Other services offer both group support and individual

encourage general practitioners and other primary care

(one-to-one) counselling in a variety of settings through­

staff who can prescribe, to play a greater role in interven­

out their communities. A third service model offers all

ing with smokers. Secondly, most attention focused ini­

smokers individual counselling, by trained nurses, in

tially on specialist support. This was because recruiting and

their own primary care centre/general practice. This lat­

training the specialist staff had to take precedence, but

ter model is typically found in rural settings. Almost all

also because of the way the monitoring and evaluation

services offer group and individual support backed up

were set up, such that only those smokers who set a quit

by pharmaceutical treatment - NRT and/or bupropion.

date and received specialist support counted towards the

0

World Health Organization

targets. Thus, there still remains work to be done in fully
engaging general practitioners and their staff.

Finally, tobacco dependence treatment has not yet been
truly "normalized" within the system. This is because the
system of funding the NHS is being changed, with control

being devolved to a more local level - to primary care

groups (serving a population of around 200 000). This
means that from April 2003 onwards, primary care groups

will take over the funding and running of these services,
and the Government's mechanism for encouraging them

to do so is the setting of targets - cessation targets for

health education. It also had the active support of the

campaigning organization ASH and the medical profes­

sions over more than 30 years. Successive Governments
accepted, at least in principle, the desirability of combat­

ing tobacco (and of raising revenue from it by increasing
taxes, which has been shown to increase demand for the
treatment products (29)). In addition, it benefited from
the existence of a national health service, with a relatively
well-developed infrastructure. And of course this story

took place in a wealthy country. Can any aspects of this
experience be exported?

example. It remains to be seen, therefore, how fully, or in

From an historical perspective the role of the medical

what form these services survive. The Government initia­

profession was critical. The Royal College of Physicians

tive has certainly raised the profile of tobacco dependence

(RCP) (which created ASH) and later the British Medical

treatment hugely, but not in itself normalized it.

Association campaigned vigorously over decades and pro­
vided crucial health and scientific information. The series

Success of the treatment services

of RCP reports was extremely influential. The national

treatment guidelines published by the HEA in 1998 were
The Government insisted on the services monitoring their

throughput and outcome from the beginning and has

not only evidence based, but were also formally endorsed
by more than 20 professional organizations, especially

published bulletins periodically. From April 2001 to March

medical and nursing bodies. Getting this endorsement

2002, the third year of the services, 220000 smokers

took time and money but almost certainly enhanced the

came to the services and set a date for stopping smoking

authority and influence of the resulting document.

(the base for all outcome statistics). Of these 120000 said
they had stopped smoking four weeks later, an increase

The United Kingdom story also depended on the fusion

from 65000 the previous year (22). During the second

of several strands at a crucial time (a new Government

year of the services going nation-wide there were around

promising action against tobacco) and on some of the

500 new staff. Using conservative assumptions, the cost

personalities involved. Obviously, the personalities can­

effectiveness of the new services was estimated at just

not be reproduced, nor can the Government, but at a

over 600 per life year gained for treated smokers aged 35

crucial time there were key people outside and inside the

44 years and 750 for those aged 45 54 years (28). These

Government who were knowledgeable about tobacco

figures are consistent with estimates published with the

addiction, who were committed to taking things forward,

original national guidelines (6). In addition to the collec­

and who learned to work together. It seems unlikely that

tion and publication of official statistics, the Government

things can move forward without enough committed indi­

also commissioned a research team to conduct a detailed

viduals - one of their key roles being to present the case

evaluation of the services. This project is ongoing and

to Government.

will publish a series of papers reporting the impact of the

The effectiveness and cost effectiveness evidence was

services, including how well they are reaching smokers,

critical and influenced the Government to act. This can

especially low-income and pregnant smokers. Although

be reproduced elsewhere if committed individuals and

the data are not yet available the Government intends that

organizations persist in making the case, backed up by

they will be published in full, in a scientific journal, and

good data. Treating dependent smokers is one of the

presented at the 12th World Conference on Tobacco or

most cost-effective interventions that a health service can

Health, in Helsinki, in August 2003.

deliver, which means that if health care systems offer such

services, they will eventually release resources (no longer

Discussion

needed to treat lung cancer for example) for other uses. In

spite of this, when the United Kingdom Government was

To what extent can this English/United Kingdom experi­

developing plans for the treatment services, their Finance

ence be reproduced in other countries? It grew within a

Ministry insisted on careful estimates of how much the

tradition of relatively well-funded addictions research and

services would cost So another key point is that tobacco

Tobacco Dependence Treatment in England

dependence treatment services are relatively cheap (they

— Learn from experience and do it even better. In

do not, for example, require enormously expensive high-

England a number of problems that could have been

tech equipment).

avoided slowed progress:

Although not all countries will be able to afford all the ele­

• Set standards for and plan training, increasing capac­

ments described here, the research does not need doing

ity if necessary. There were no national standards

again everywhere, and much of the expertise is exportable.

governing training and no control over its quality or

There are several countries now implementing treatment

quantity, yet a huge training capacity was a predict­

for tobacco dependence, and thus there are more and
more people capable of helping (including with training).

Lessons learned
— Present the evidence and arguments until they are

able requirement of the project.

• Standardize the provision of pharmaceutical treat­
ments and make them as widely available/accessible

as possible. This also means make them afford­
able. When the project started, neither NRT nor

accepted. The English experience suggests this can be

bupropion was available on NHS prescriptions. Their

done. Since funding will always be an issue, the effec­

introduction on prescription, as well as being made

tiveness and cost-effectiveness evidence and argu­

more widely available over the counter and through

ments are crucial. In England, smoking costs the health

general sale, was done in a piecemeal way; again the

service about £1,500 million each year. The smoking

need for widely available pharmaceutical aids was

treatment services are costing approximately £25 mil­

lion a year. Funding smoking cessation interventions

totally predictable.

• Give the new services time to become well estab­

will have a knock-on effect and reduce other health­

lished. An enterprise as huge as this takes time

care expenditure. The anomalous position of nicotine

to develop, but the short-term funding promised

addiction compared with the provision of treatment for

caused recruitment difficulties and staff losses. We

other addictions might also be highlighted.

suggest that whatever initiative or level of funding a

— Obtain necessary government commitment to develop

country proposes to develop treatment for tobacco

a treatment system nationally. In England this took

dependence it should have at least five years guar­

many years. However, it need not take so long in

anteed development to promote stability and com­

other countries since much of the evidence and argu­
ments are available from other countries' experience.
For example, WHO's Europe Partnership Project in

partnership with the British Government, The case for
commissioning smoking cessation services (18) , could
be adapted by other countries.

— Work with doctors at as high a level as possible and
benefit from their influence. The voice and involve­

mitment from its staff.
• Whereas targets for numbers of smokers quitting
through the smoking cessation services can be help­

ful, care needs to be taken that this does not create

a tension between throughput and reaching priority
groups. In England, the key priority group was the

more deprived smoker who may be more dependent
and therefore more in need of help.

ment of the medical profession was crucial in Britain,

so the lesson to smoking cessation specialists and cam­
paigners is work with doctors at as high a level as pos­

sible and benefit from their influence. If they first need
educating then do that first.

— Make appropriate investments. Up to £50 million
was announced by the Government for educational
programmes and up to £60 million for treatment sys­

tems. There has been some debate as to whether this

balance of investment is the right one. It is important

— Work together and share the load. This includes

researchers, campaigners, health professionals and
government officials. This may sound obvious but it

doesn't always happen. No one organization or group
can do everything. In England a number of mistakes
were made that could have been avoided with more

sharing of expertise and foresight.

that a significant investment be made in developing

smoking cessation services, but it is vitally important

to maintain the wider tobacco control strategy with
appropriate investment made in other areas, such as
mass media campaigns. Certainly countries that do not

yet have population approaches to motivating smokers
to stop will probably not want to start by developing

treatment services.

9

World Health Organization

References

interventions for the health care system. Thorax 53, 1998,
Supplement 5 Part 1 pp 1-17.

1.

Department of Health. Statistics on smoking: England, 7978

onwards. London, Department of Health, July 2000.

17.

West R, McNeill A, Raw M. Smoking cessation guidelines for
health professionals: an update. Thorax 55, December 2000,

2.

Department of Health. Smoking Kills: A White Paper on

987-999.

Tobacco. London. The Stationary Office, 1999.
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of nicotine replacement therapy (NRT) and bupropion for

smoking cessation Technology Appraisal Guidance - No. 39.

Wilkinson R, eds. Social Determinants of Health. Oxford,
Oxford University Press, 2000.

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London. NICE, 2002.
19.

British Medical Journal 323, 2001, 1140-1141 (17th

November) http://bmi.com/cgi/content/full/323/7322/1140
20.

Partnership Project & Smoke Free London, 2001. At website:

Suppl 5 Pt2:S1-38.
7.

8.

www.ash.org.uk/html/cessabon/servicescase.pdf html and

Parrott S et al. Guidance for commissioners on the cost effec­
tiveness of smoking cessation interventions. Thorax 1998, 53

Raw M, McNeill A, Watt J. The case for commission­
ing smoking cessation services. London, WHO Europe

Peto R et al. Mortality from smoking worldwide. British

Medical Bulletin, 1996; 52 (no. 1):12-21.
6.

Raw M et al. National smoking cessation services at risk.

Royal College of Physicians Tobacco Advisory Group.
Nicotine Addiction in Britain. London: Royal College of

Physicians, 2000.
5.

National Institute for Clinical Excellence. Guidance on the use

Jarvis M, Wardle J. Social patterning of individual health

behaviours: the case of cigarette smoking. In: Marmot M,

www.ash.org.uk/html/cessabon/servicescase.html

21.

McNeill A etal. Public and private sector partnerships, the

Doll R, Hill AB. Smoking and carcinoma of the lung. British

WHO Europe Partnership Project to reduce tobacco depend­

Medical Journal ,1950; ii: 739.

ence: a case study. Paper forthcoming.

Royal College of Physicians. Smoking and health. London,

22.

Department of Health. NHS helps over 120000 smokers
kick the habit. London, Government press release, 8 August

Pitman Medical Publishing, 1962.

2002. http://tap.ukwebhosteds.com/doh/intpress.nsf/page/
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Royal College of Physicians. Smoking and health now.

2002-0345?OpenDocument

London, Pitman Medical and Scientific Publishing, 1971.

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British Medical Association Public Affairs Division. Smoking

McNeill A, Bates C. Smoking cessation in primary care. How
to spend NHS money much more effectively. ASH, July

out the barons. The campaign against the tobacco industry.

2000. Available at: www.ash.org uk

Chichester, John Wiley & Sons, 1986.
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United States Department of Health and Human Services.

Jarvis MJ. Why Nicorette should be freely prescribed. World

Medicine, 1982,17: 22-23.

Nicotine addiction. Rockville, DHHS Public Health Service,
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Russell MAH et al. Effect of general practitioners advice
against smoking. British Medical Journal, 1979, 2:231-235.

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Russell MAH et al. Effect of general practitioners' advice

against smoking. British Medical Journal, 1979;2:231-235.

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Russell MAH et al. District programme to reduce smoking:
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Jarvis MJ et al. A randomised controlled trial of nicotine

tioners. Bribsh Medical Journal, 1987, 295:1240-1244.

chewing gum. British Medical Journal, 1982; 285: 537-540.

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Russell MAH et al. District programme to reduce smoking:

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16.

Raw M, McNeill A, West R. Smoking cessation guidelines for
health professionals. A guide to effective smoking cessation

Stapleton J. Cost effectiveness of NHS smoking cessation

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cigarette smuggling. International Journal of Tuberculosis
and Lung Disease, in press, 2002.

Tobacco Dependence Treatment in England

Acknowledgements
We thank Dawn Milner and Robert West for extremely helpful
comments on a draft of this paper.

Note
This paper was completed in November 2002 with minor amend­

ments added in April 2003. In that time there have been changes
in the funding of the NHS services and organization that will
affect the service.

11

Tools for Advancing Tobacco Control

in XXIst century:

Success stories and lessons learned

Outils pour poursuivre la lutte antitabac

au XXPsiecle:

Experiences concluantes
et nouveaux enseignements

Taxation (including
Smuggling
Control

Report on Smuggling Control in Spain

WHO/NMH/TFI/FTC/03.6

Tobacco Free Initiative would like to thank
the Centers for Disease Control and Prevention (CDC), Atlanta, USA

for their generous support for this project.

© World Health Organization 2003

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Printed in World Health Organization. Geneva.

I

Report on Smuggling
Control in Spain
Luk Joossens
Non-Smokers' Rights Association

and the Smoking and Health Action Foundation
Toronto, Ottawa, Montreal

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World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices
for their contribution to this project.

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Report on Smuggling Control in Spain

Introduction
Tobacco smuggling has become a critical public health

issue because it brings tobacco on to markets cheaply,

A huge smuggling problem,

despite low prices

Joossens and Raw (1998, 2000, 2002) showed that tobac­

making cigarettes more affordable and thus stimulates

co smuggling defies apparent economic logic. Common

consumption. The result is an increase in the burden of ill
health caused by its use. According to the tobacco trade

sense might suggest that cigarettes would be smuggled
from countries where they are cheap (southern Europe, for

report World Tobacco 2002 a major feature of the world
cigarette market is the continued growth in smuggling and

example) to expensive countries (such as northern Europe)

counterfeit trade, which accounts for a minimum of 8% of

these countries, as the tobacco industry claims. Although

the world cigarette consumption at around 400 thousand

this does happen, it is not the largest type of smuggling,

million pieces/?)

and in Europe there is far more smuggling from north to

and that this is due simply to price differences between

south rather than the reverse. (2)
Smuggled tobacco products represent both a threat to

public health and to government treasuries, which are los­
ing thousands of millions of dollars or euro in revenue.

Using 1995-1997 data on nine countries from the
European Confederation of Cigarette Retailers and other

sources, Joossens and Raw classified the 15 European

Smuggled cigarettes became a major concern for govern­

Union (EU) countries and Norway as follows: high-smug­

ments and international organizations such as the World

gling countries, with a contraband market share of 10%

Health Organization, the World Customs Organization,

or more (Spain 15%, Austria 15%, Italy 11.5%, Germany

the World Bank, the International Monetary Fund and the

10%), medium-smuggling countries, with a contraband

International Criminal Police Organization (Interpol). At

market share between 5% and 10% (Netherlands 5-10%,

a conservatively estimated average tax of USS 1.0025 to

Belgium 7%, Greece 8%, and probably Luxembourg and

USS 1.50 per cigarette pack (this is much higher in most

Portugal, but no studies are available), and low-smuggling

developing countries) cigarette smuggling (20 thousand

countries, with a contraband market share of less than

million packs) accounts for USS 25 to USS 30 thousand

5% (France 2%, the United Kingdom 1.5%, Ireland 4%,

million being lost by governments every year.

Sweden 2%, Norway 2%, and probably Denmark and

The tobacco industry has argued that tobacco smug­

Finland, but no studies are available).(2) The results can be

gling is caused by market forces—by the price differ­

seen in Table 1. (Note that the situation has changed in a

ences between countries, which create an incentive to

number of the countries since the study was done.)

smuggle cigarettes from "cheaper" countries to "more

expensive" ones. The industry has urged governments to
solve the problem by reducing taxes, which will also, it
says, restore revenue. The facts contradict all these asser­

tions. Smuggling is more prevalent in "cheaper" countries

and, where taxes have been reduced, such as in Canada,
consumption has risen and revenue fallen. There are,

however, countries that have solved the problem by better
control, Spain being the most impressive example to date.
There are two main reasons why the example of Spain in

terms of combating smuggling is impressive:

— The country had a huge smuggling problem, despite
low prices.

— It effectively reduced smuggling without reducing
prices

3

World Health Organization

the cheapest in the European Union, smuggled cigarettes

Table 1

had an estimated market share of 15% in 1995.®

Prices of cigarettes (in USS, June 1997) and level of
smuggling (1995) into countries of the European Union

According to the EU lawsuit against Philip Morris, RJ
Reynolds and Japan Tobacco, filed on 3 November

Country

Price

Level of smuggling

Spain

1.20

high

Portugal

1.75

medium*

2000 in New York under the United States Racketeering
Influenced and Corrupt Organization Act (RICO), Spain

has been a primary destination for smuggled Winston

cigarettes for so long that the smugglers are sometimes

Greece

2.06

medium

Italy

2.07

high

because of the way RJR mark and label their cigarettes,

Luxembourg

2.12

medium*

the company could identify which smuggled RJR cigarettes

in the marketplace had been originally supplied by RJR

known as "Winstoneiros". According to the EU lawsuit,

Netherlands

2.43

medium

Austria

2.69

high

Belgium

2.95

medium

Germany

3.02

high

France

3.38

low

Finland

4.26

low*

Ireland

4.27

low

EU complaint, RJR took steps to prevent the unauthor­

United Kingdom

4.35

low

ized smuggling. They developed a particular presentation

Denmark

4.55

low*

Sweden

4.97

low

Norway

6.27

low

Notes: The table shows the price (in USS at 1 June 1997) of

USA, and which were smuggled into the country by per­
sons without authorization of RJR.
As the demand for Winston in Spain rose through the

1990s increased numbers of "lower quality" Winston from

other sources were being smuggled into Spain, interfering
with the smuggling authorized by RJR. According to the

of Winston cigarettes known to the Spanish consumer as
patanegra. The patanegra presentation could be distin­

guished from the other "lower-quality" Winstons by dis­
tinctive markings and because they did not have the blue

sticker found on most Winston cigarettes.

20 cigarettes from the most popular price category. Sources for

It was alleged that RJR produced the patanegra presenta­

prices are the Commission of the European Communities and

tion specifically for their best smuggling customers, to

the Norwegian Council on Tobacco and Health.

insure that they could maintain their competitive advan­

• Probably details of how this index was constructed are given
in the text

tage over other smugglers and so that RJR could increase
their market share (because if you can guarantee good
quality you will sell more and increase market share). The

The correlation between high prices and high levels of

patanegra presentation was developed specifically for the

smuggling claimed by the tobacco industry simply does

Spanish market and sold only in Spain. According to the

not exist. In fact, countries with very expensive cigarettes

EU lawsuit, it was one of the examples that showed how

do not have a large smuggling problem. Table 1 shows

RJR maintained and exercised control of the smuggling
operations in Spain. (4)

high levels of cigarette smuggling in the south of Europe

rather than the north. Other factors than price levels that
make cigarette smuggling more likely include corruption,

Another source of smuggled cigarettes in Spain and the

public tolerance, informal distribution networks, wide­

EU was Andorra. In a 1992 BAT internal tobacco indus­

spread street-selling, and the presence of organized crime.

try document, the illegal cigarette trade in Andorra was

described in the following way:
Effective reduction of smuggling

without reducing prices

Smuggling is a traditional and highly lucrative trade in
Andorra. The growth has increased rapidly in recent years

4

Spain is one of the few countries in the world to have

as Andorran supply has replaced that which used to enter

tackled smuggling successfully. It did not do so by reduc-

Spain by sea and has been subjected to increased controls
because of the links with the drugs trade.” (5)

ing tobacco tax. Despite Spanish cigarettes being among

Report on Smuggling Control in Spam

Between 1997-1998 there was concerted action at nation­

al and European levels to reduce the supply of contraband

Table 3

cigarettes. Close collaboration among the authorities in

Cigarette sales in Spain

Andorra, Britain, France, Ireland, Spain and the European

(thousand million pieces)

Anti-Fraud Office (OLAF) reduced the supply of smug­
gled cigarettes from Andorra. Actions included sealing the

Andorran border, and having civil guard brigades patrol
valleys and hills to make smuggling more difficult. The

European Anti Fraud Unit led a first mission to Andorra
in March 1998, accompanied by representatives from

the neighbouring countries (France and Spain) and from
cigarette exporting countries (Ireland and the United

Kingdom). The enquiries revealed a lack of appropriate

legislative instruments in Andorra to prevent and combat
fraud. In November 1998 a EU Commission mission visited

1996

72

1997

78

1998

87

1999

86

2000

88

2001

90

Source; Comisionado del Mercado de Tabaco

the Andorran Government and found that attitudes had
changed fundamentally. The laws on customs fraud and
the control of sensitive goods and the law amending the

criminal code and making smuggling a crime were pub­
lished respectively in the Andorran Official Journal on 4

Andorra is important because it illustrates the role of
the tobacco industry. Andorra was not only supplying

illegal cigarettes to the Spanish market but also to the
United Kingdom. Exports from the United Kingdom to
Andorra (which has a population of only 63 000) increased

March 1999 and 7 July 1999.(6)

from 13 million cigarettes in 1993 to 1 520 million in

As a result, contraband cigarettes which had accounted

1997. Since few of these cigarettes were legally re-export­

for an estimated 12% of the Spanish market in early

ed and Andorran smokers do not generally smoke British

1997, held only 5% by mid-19991 and only an estimated

brands, then either each Andorran (including children and

2% in 2001. Sales of legal cigarettes increased from

non-smokers) was smoking 60 British cigarettes a day

78 thousand million in 1997 to 87 thousand million in

in 1997 or these cigarettes were being smuggled out of

1998 (see Table 3), and tax revenue increased by 25%

Andorra. It seems obvious that the companies would know

in the same year (see Table 2). According to the Spanish

what was happening to their cigarettes. In a television

customs authorities, their success was not due to control­

interview on the BBC's Money Programme of 8 November

ling distribution at street level, which is almost impossible,

1998, a spokesperson for the tobacco company (Gallaher)

but to reducing the supply into the country at "container

said: "We will sell cigarettes legally to our distributors in

level” through intelligence, customs activity and coopera­

various countries. If people, if those distributors subse­

quently sell those products on to other people who are

tion, and technology*2.

going to illegally bring them back into this country, that is
something outside of our control." (7)

Discussion
Table 2
Excise revenue from cigarette sales in Spain, 1996-2000

(billion Pesetas)

___________ __________________

____________

1996

443

1997

516_______ ____________

1998_________________

646

1999_________________
2000_________________

The tobacco industry has often claimed that smuggling

is more prominent in high-tax countries and that the

best way to tackle cigarette smuggling is by reducing the

demand and by lowering taxes. In fact, cigarette smuggling

’ (Ignacio Garcia, Customs and Excise, Madrid, personal
communication)

667
2 (Ignacio Garcia, Customs and Excise, Madrid, personal

742

Source: Spanish Customs and Excise

______________

communication)

World Health Organization

occurs in all parts of the world, even in countries where

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//www.nyed.uscourts.gov/pub/rulings/cv/2000/

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00cv6617cmp.pdf

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and illegal, as testified to by many documents from the

6.

Commission of the European Communities, Protecting the

Guildford archives.® What follow logically from this, is the

Communities' financial interests and the fight against fraud

need to cut off the supply of cigarettes to the smugglers.

- Annual report 1998, COM (1999) 590 final, Brussels, 17
December 1999.

Economic analysis of the effect of cigarette prices in Spain
and the analysis of smoking histories from the national

health survey 1993-1995-1997 has shown that the price

increase of black cigarettes had a significant effect on

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rette smuggling in the UK and Sweden with recommenda­

prevalence, but the price increase of blond cigarettes did

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not.® Smuggling may be an explanation for this dif­

ference between the effect of price increases of blond

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Nicholas AL. How important are tobacco prices in the

and dark cigarettes as smuggling of cigarettes in Spain

propensity to start and quit smoking? An analysis of smok­

occurred mainly with blond (Winston) cigarettes, which

ing histories from Spanish National Health Survey, Health

were promoted on the illegal market as "high-quality

Economics, 11:521-535 (2002).

cigarettes" (the so called Patanegra Winstons). The ready
availability of lower-price smuggled blond cigarettes

undermined the effect that price increases of legitimately
sold cigarettes should have had.
While the success of the fight against smuggling in Spain

was evident, the impact of the reduction of smuggling on

smoking prevalence is unclear. Smoking prevalence among
women remained stable at 27% in 1995 and 2000-2001,
but decreased among men from 47% in 1995 to 42% in
2000-2001. (7Q) It is unclear whether the decline of smok­

ing among men is linked to the reduction of cigarette
smuggling, but it might be, since the action against smug­

gling greatly reduced the ready supply of cheap Winstons
available to consumers.

10.

Ministerio de Sanidad y Consume, Encuesta Nacional de

Salud 2001, Avance de resultados, Madrid, 2002.

Tools for Advancing Tobacco Control
in XXIst century:

Success stories and lessons learned

Outils pour poursuivre la Suite antitabac
au XXIsiecle:

Experiences concluantes
et nouveaux enseignements

Surveillance and
Monitoring

The Surveillance and Monitoring of
Tobacco Control in South Africa

WHO/NMH/TFI/FTC/03.7

Tobacco Free Initiative would like to thank
the Centers for Disease Control and Prevention (CDC), Atlanta, USA

for their generous support for this project.

© World Health Organization 2003

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Printed in World Health Organization. Geneva.

The Surveillance and Monitoring

of Tobacco Control in South Africa
Dehran Swart and

Saadhna Panday
Specialist Scientist,

National Health Promotion R&D Group
Medical Research Council of South Africa

World Health Organization

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

WHO Regional Office for Africa (AFRO)

Cite du Djoue

Boite postale 6

WHO Regional Office for Europe (EURO)
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Telephone: +(1-321) 95 39 100/+242 839100

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Telephone: +(91) 11 337 0804 or 11 337 8805

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Telephone: (00632) 528.80.01

Egypt
Telephone: +202 670 2535

The Surveillance and Monitoring of Tobacco Control in South Africa

Introduction

maximum permissible levels of tar and nicotine. The regu­

lations were implemented in 2001/6)
South Africa is situated at the southernmost tip of

Africa and is divided into nine provinces: Western Cape,
Eastern Cape, Northern Cape, KwaZulu-Natal, Free State,

Gauteng, Mpumalanga, Limpopo Province and North
West Province. It has a population of approximately 43

million, half of whom are under 19 years of age/7) South

Africa is considered a middle-income, developing country

During the 1990s, there was a concerted effort by the

research community to alleviate the risks associated
with tobacco-use by collecting data on the extent of its
use. Reddy and associates (7), in a study carried out in

February 1995, reported that 34% of adult South Africans,
or a total of seven million adults, smoked.

and has extremes of wealth and poverty due to 350 years

A household survey in 1996 showed that the overall

of colonialism and apartheid 1. Almost 78% of the popula­

smoking prevalence among adults remained at 34%.

tion are "Black/African" (1) and they represent the major­

However, there had been an increase in the prevalence of

ity of those living in poverty.(2) About 72% of the poor

smoking among adults in five provinces when compared

live in rural areas. (.2) There are 11 official languages in

to the prevalence rates of the February 1995 survey.(8)

South Africa.

The smoking prevalence analysed by "race" and gen­

The history of tobacco control in SA dates back to the
1970s when tobacco use was banned in cinemas, followed
by a ban on smoking on domestic flights/3) In 1993 the

first Tobacco Products Control Act (4) was passed and
was implemented in 1995. It regulated smoking in public

der showed that the rate had increased for "Coloured",

"Indian" and "White" males; and for "Black/African"
"Indian" and "White” females. From February 1995 to
October 1996, smoking prevalence in the 18-24 age
group increased from 31% to 36%.

places, prohibited tobacco sales to minors under the age of

By 1998, Meyer-Weitz et. al (9) reported that the smok­

16 and regulated some aspects of advertising of tobacco

ing prevalence rate for adults had dropped to 25%. This

products such as labelling. It was not a comprehensive act

is consistent with the smoking rate of 24.6% obtained

in that it had the following shortcomings: radio advertis­

from the South African Demographic and Health Survey

ing was still allowed; smoking in public places was not

(SADHS)/70, 77) According to the All Media and Product

banned completely; the definition of a public place was

Survey (AMPS), smoking prevalence decreased from

not specified, and no enforcement mechanism was built

32.6% in 1993 to 27.1% in 2000/72) The dramatic

into the act. In 1995, health warnings were introduced

decrease in smoking prevalence from 34% in 1996 to

for all tobacco packaging and tobacco advertising on bill­

24.6% in 1998 registered by SADHS could possibly be

boards. Due to the shortfalls of the 1993 Act, the Tobacco

attributed to the introduction of health warnings on ciga­

Products Control Amendment Act was passed in 1999/5)

rette packages and all tobacco advertisements, together

It primarily bans all advertising and promotion of tobacco

with the extensive media coverage that the impending

products, including sponsorship and free distribution of

tobacco control legislation received during that period.

tobacco products; it restricts smoking in public places,

Media coverage in particular revolved around debates

including the workplace and public transport; it stipulates

concerning the pros and cons of the intended legisla­

penalties for transgressors of the law, and specifies the

tion. Strong arguments were put forward by government,

NGOs, and researchers via the media as to the health,
economic and social benefits of comprehensive tobacco
During the apartheid years, all South Africans were classified

control legislation. In addition, the consistent increase in

in accordance with the Population Registration Act of 1950

tobacco excise tax may also have had an impact on the

into "racial groups" namely "Black/African"(people mainly

prevalence of smoking.

of African descent), "Coloured" (people of mixed descent),
"White" (people mainly of European descent) or "Indian"

In 1999, the Global Youth Tobacco Survey (13), the first

(people mainly of Indian descent). The provision of services

nationally representative study on tobacco use among

occurred along these "racially" segregated lines. The dispro­

adolescents was conducted in SA. About 23% of the sam­

portionate provision of services to different "race groups" led

ple reported being current smokers (smoked cigarettes at

to inequities. Information is still collected along these "racial"

least one day in the 30 days preceding the survey). Some

divisions in order to redress these inequities. In no way do the

18.5% of students reported first smoking cigarettes before

authors subscribe to this classification.

the age of 10. Almost a fifth of the sample (18.2%) had

World Health Organization

used tobacco products other than cigarettes such as chew­

Laboratory Services and the University of Witwatersrand;

ing tobacco and snuff.

it is also funded by these institutions.(74) The National

Tobacco-related morbidity and mortality is monitored by
using the data from the National Cancer Registry. Data
collected for 1993-1995 showed that lung cancer among

"White" women was not in the top five types of cancer
before 1992 but, by 1995, it was fourth. (14) With regard

to "Black" women, lung cancer featured fifth in 1995 but
previously had not been one of the major forms of can­

cer among them. (14) Lung cancer among "Coloured"
women was ranked second, and fifth among "Indian"

women.(14) Between 1993 and 1995, lung cancer was

the third most common cancer in "Black" males and the
second most common in “Coloured" males.(14) It was the
fourth most common in "White" males and the third most

common in "Indian" males. (7 4) However, by 2000, trends

Cancer Registry was set up in the absence of a Population

Based Cancer Registry. It collects information from

approximately 70 private and public histology, haematol­
ogy and cytology laboratories. The information is based
on histologically verified cancers including those caused by

tobacco use. This information is sent on a voluntary basis
and thus at irregular intervals.(17) The data are extracted

from the pathology report. This report is not standardized
and varies from laboratory to laboratory. Data collection
covers cases from all age groups. The essential items of

information collected are: name, date of birth, age, date

of diagnosis, method of diagnosis, primary site of cancer,
morphology, extent, gender and ethnic/population group,

and usual home address.

showed a stabilisation of tobacco-related cancers.(15)

The Household Surveys

Tobacco-related mortality is also monitored by the new

The inclusion of tobacco-related questions in the

death notification system. This new system was imple­

Household Survey dates back to 1994. These questions

mented in 1998 and records the smoking history of the

were included to gather information on tobacco use

deceased. A 5% sample of 13000 forms was used to

among South African adults between 1994 and 1998. The

conduct a case control study.(76) It showed significantly

questionnaire was put by the interviewer to adults aged

increased relative risk of death due to lung (RR=3.3),

18 and older at the respondents' home. The survey was

oesophageal (RR=4.1), stomach (RR=2.2) and digestive

conducted twice a year, in February and October. Smokers

diseases (RR=1.6), tuberculosis (RR=2.5) and other lung

were defined as those who smoked one or more ciga­

diseases (RR=1.6) among the deceased who had smoked 5

rettes, pipes or cigars per day; ex-smokers were defined as

years prior to their death.(16)

those who had smoked at least once a day and stopped

for a period of six months and non-smokers were defined

Surveillance of Tobacco in
South Africa

as those who never smoked or smoked less than one ciga­

rette a day. In the February 1996 survey, the definition of
smoking status used was worded slightly differently but it

South Africa has a short history with regard to the estab­

also categorised participants as smokers, ex-smokers and

lishment of surveillance systems and mechanisms for

non-smokers.(9) This survey has been discontinued.

monitoring tobacco use. Even though policy development
in South Africa preceded the establishment of surveillance

All Media and Product Survey (AMPS)

systems, continuous monitoring and evaluation systems

The All Media and Product Survey (AMPS) is conducted

must be in place so that scientific data can be used to jus­

by the South African Advertising Research Foundation in

tify amendments to the policy and programmes. However,

order to generate data about consumer trends in advertis­

in the absence of these systems, tobacco was included as

ing and the mass media as well as in product usage.(18)

part of other surveillance mechanisms. In this way trends

The AMPS survey is carried out in the adult population

in tobacco use and tobacco-related morbidity and mortal­

of South Africa aged 16 and over. The questionnaire is

ity were measured over time.

administered by interviewers in the participants' home.
The study is conducted at least once a year using the same

The Cancer Registry

4

questions. Those are limited to tobacco usage (they do

The National Cancer Registry, which was established

not investigate attitudes towards tobacco use), to tobacco

in 1986, is a co-operative venture of the Department

control policies, smoking initiation and exposure to second

of Health, the Medical Research Council, the Cancer

hand smoke. Smokers are defined as those individuals

Association of South Africa, the National Health '

who spend money on cigarettes.(T9) The tobacco-related

The Surveillance and Monitoring of Tobacco Control in South Africa

questions are not standardized but are repeated without

was administered to adult household members aged 15-

changes each year. The study is funded by the South

49.

African Research Foundation, which receives an annual

endowment from the Marketing Industry Trust (MIT). MIT

is in turn financed through an industry levy on advertising
expenditure that is collected by media owners.("78)

0

The following definitions of smoker categories were used:

— regular smokers: adults who smoked daily or occasion­
ally;

— daily smokers: adults who smoked daily at the time of
Death Notification
As part of the Vital Registration Infrastructure Initiative, a

the interview;

— light smokers: daily smokers who smoked 1-14 tobac­

new death notification form was approved by the govern­

co equivalents per day (one tobacco equivalent was

ment in July 1998 and adopted in September 1998.(20) A

calculated as one manufactured cigarette (1g), one

question on the smoking status of the deceased, "Was the

handrolled cigarette (1g), one pipe smoked (1g: con­

deceased a smoker five years ago?", was included in the

servative estimate of the amount of tobacco smoked in

form. This question was added in order to collect informa­

tion on tobacco-related mortality. The tobacco-related
information was evaluated in a case-control study that
involved a 5% sample of death notification forms.(16) A

15% sample of death notification forms will be analysed
in 2003.(17) It is envisaged that the data collected will be

analysed on a 2-3 year cycle.dZ)

pipes), one cigar, cheroot or cigarillo;

— heavy smokers: daily smokers who smoke 15 or more
tobacco equivalents per day;

— ex-smokers or quitters: adults who reported previously
smoking daily but did not smoke at all at the time of
the survey;

— non-smokers: adults who had never smoked tobacco
South African Demographic
and Health Survey (SADHS)

but who may have used smokeless tobacco products
Due to the large sample size of the study, it was possible

The first nationally representative South African

to identify socio-economic and socio-demographic char­

Demographic and Health Survey was conducted in 1998

acteristics that are related to tobacco-use. This makes it

to provide accurate baseline data on a range of demo­

possible to prioritize the provision of programmes to target

graphic and health indicators including chronic health

groups in the population.

conditions and lifestyles that affects health status. ("70) The
study was primarily funded by the National Department of

The findings of the SADHS were disseminated in the fol­

Health, with contributions from Macro-International and

lowing ways:

USAID. It is envisaged that this survey with interviewer-

— preliminary research report

administered household questionnaire will be repeated in

— final report

South Africa every five years.(21, 22) The tobacco-related

questions were derived from the 1998 WHO Guidelines

— press releases

for controlling and monitoring the tobacco epidemic.dO,

— journal articles

23) The questions covered adult smoking patterns, their

— dissemination workshops at various levels within the

opinions on the health effects of tobacco use and their
exposure to environmental tobacco smoke in the home

and at the workplace.CTO, 11) Participants were also asked

about their exposure to smoke, dust, fumes or strong
smells at their workplace. Data on tobacco-related mor­
bidity was also collected: the symptomatology of chronic

bronchitis, which was based on four standardized ques­
tions on chronic productive coughing; airflow limitation

(asthma) was measured using four standardized questions
on wheezing and chest tightness, and peak expiratory flow

Department of Health.

In 2003, the SADHS will include a more robust question­

naire on tobacco use as it was developed for the Noncommunicable Disease Risk Factor Surveillance (STEPS

programme) by WHO/?)) This is necessary because of
problems experienced with the ordering of questions and
with low levels of literacy and numeracy. (21)

Global Youth Tobacco Survey (GYTS)

rate was also measured for each participant. Questions

The Global Youth Tobacco Survey (13) is a multi-country

were asked on other tobacco-related illnesses, including

study that forms the second phase of a 3 phased project

tuberculosis, emphysema and cancers. The questionnaire

initiated by the World Health Organization's Tobacco Free

5

World Health Organization

Initiative to "create a generation of tobacco free children

The findings of the GYTS were presented to the national

and youth". The National Departments of Health and

and provincial Ministers of Education. This resulted in the

Education, in collaboration with the Medical Research

National Department of Education declaring nicotine an

Council, deemed it necessary to join this initiative due to

addictive drug and including tobacco use in its drug policy

a lack of nationally representative data on tobacco use

for schools.

among adolescents. South Africa was one of the first
13 countries to conduct this study. The 1999 study was

funded by the National Department of Health, UNICEF
and MRC. The research instrument was designed at a

workshop convened by WHO and the CDC. It consists of
a "core" set of questions to be used by all countries. The

core questions included an investigation of the prevalence
of tobacco use, including cigarette smoking, and current

use of smokeless tobacco, cigars or pipes. The question­
naire was also meant to assess students' attitudes, knowl­

edge and behavior related to tobacco use and its health

impact, including cessation, environmental tobacco smoke
(ETS), media and advertising, minors’ access, and school

The purpose of repeating the GYTS in 2002 was to moni­

tor changes in smoking prevalence within and between
gender and "race" groups as well as to monitor provincial
and regional trends. Monitoring the trends in underage

sales of tobacco products, tobacco advertising and pro­

motion, and exposure to second hand smoke in public
places between 1999 and 2002 is particularly pertinent to

South Africa. During this period, a new tobacco law that
re-emphasises the ban on underage sales, prohibits all

tobacco advertising and promotion, and limits smoking in
public places, was enacted.

The 1999 GYTS showed a high smoking prevalence

curriculum. In addition, the questionnaire was designed to

among adolescents, high percentages of smokers wanting

be flexible enough to include specific issues and individual

to quit, and high relapse rates. As a result, the Medical

needs of each of the participating countries (i.e. optional

Research Council of South Africa and Emory University,

questions could be added). The GYTS is a school-based,

Atlanta, USA made a successful application to the

self-administered tobacco specific survey which focuses

National Institute of Health to fund a study that will test

on adolescents aged 13-15 (Grades 8-10). The study was

two school-based tobacco prevention and cessation pro­

repeated 3 years later in 2002 and was funded by WHO

grammes.

and MRC. The main definitions of smokers used were:

— ever smokers: those who had smoked a cigarette, even
one or two puffs;

Measuring compliance levels

with the smoke free policy of the Tobacco
Products Control Amendment Act of 1999.

— current smokers: those who had smoked cigarettes on
at least one day in the 30 days preceding the survey.

This study was initiated in 2002 as a means to measure
compliance levels with the newly implemented Tobacco

The results of the GYTS 1999 were disseminated in the

Products Control Amendment Act of 1999 and its regula­

following ways:

tions of 2001, namely the restriction on smoking in public

— report of research findings;

— fact sheet with summary of national and provincial
results;

places in both formal and informal restaurants and pubs,

and in other places of entertainment.^,25) The study will
be conducted in three of the nine provinces. Information

will be collected by means of one-to-one interviews and

— posters at the national launch;

telephone interviews for both the qualitative and quantita­

— poster presentation at the eleventh World Conference

tive phases of the study. The research instruments have

on Tobacco or Health;

— national launch held at one of the participating

schools;

not been standardized against any guidelines. The findings
of the study will be used to develop guidelines for the
monitoring and enforcement of the smoke free policy as
well as to compare compliance levels between provinc­

—- press release;

— presentations to provincial and national Ministers of
Health and Education;

— presentation to the National Department of Health,

es.^) It is intended that the study be repeated nationally

on a three year cycle and that its scope will be expanded
to include all public places.(25) The study will be con­

ducted among smoking and non-smoking patrons as well

Occupational Health, Health Promotion and

as among owners of establishments. The questions will

Environmental Health Cluster.

assess the level of compliance, reasons related to the levels

The Surveillance and Monitoring of Tobacco Control in South Africa

of compliance, and patrons' and owners' attitudes to and
perceptions of the tobacco legislation. The tobacco control

Surveillance of tar and nicotine content of
cigarettes.

legislation and regulations in South Africa will be amended
during 2003. The follow-up study will also evaluate the

The Minister of Health has, in terms of section 3A of

implementation of these amendments and compare com­

the Tobacco Products Control Act of 1993, specified the

pliance levels with the 2002 study. The South African

amount of tar and nicotine that is permissible in tobacco

government, through the National Department of Health,

products. According to the Tobacco Products Control

is funding the study.

Amendment Act of 1999, the tar yield of cigarettes market­

ed in the Republic of South Africa must not be greater than
Youth Risk Behaviour Survey

The YRBS is a multi-risk behaviour study that has been

conducted over the past 10 years by the CDC in the USA.

Due to a lack of nationally representative data on multi­
risk behaviour among young people attending schools, the

National Department of Health in SA awarded the MRC

a grant to conduct the first YRBS in SA during 2002.(26)
The CYTS and the YRBS were conducted in the same

schools but with different classes in the course of 2002.
The self-administered questionnaire was completed by

grades 8-11 (13-16 years) students. The seven tobacco
questions were common to both the GYTS and YRBS

questionnaires and were based on the questions developed

at the global planning meeting to expand the multi-risk
behaviour survey to other countries that was convened by

WHO and the CDC in December 2001. Questions were

asked on current use of cigarettes and tobacco products

other than cigarettes, current use of smokeless tobacco,
age of initiation of cigarette use, attempts to quit cigarette

use during the past year, exposure to second-hand smoke

15 mg per cigarette, and the nicotine yield not greater than

1.5 mg per cigarette, as from 1 December 2001. As from
1 June 2006, the tar yield of cigarettes must not be greater
than 12 mg per cigarette, and the nicotine yield not greater
than 1.2 mg per cigarette. The legislation also stipulates
that the tar and nicotine content of cigarettes be measured

to check that they are within the values prescribed by leg­
islation and that they comply with the values on the pack

imprints.(2Z) Test House, a company affiliated to the South

African Bureau of Standards (SABS), conducts the tests.(28)

The cigarette laboratory is part of the Chromatographic

Services business unit and consists of 2 staff members. Tests
are conducted on all cigarettes that are legally sold on the

South African market. Determination of the tar and nicotine
content of cigarette smoke is conducted according to ISO

4387 2: determination in cigarettes of total and nicotinefree dry particulate matter is carried out using a Filtrona,

linear type smoking machine, 300 series. There are currently

77 cigarette brands that are sampled every two months by
SABS representatives. These test results are reported to the

during the past week, and the smoking status of parents

and guardians. The study is intended to be repeated every

three years. Current smokers were defined as those stu­

2 WHO has made recommendations (see reference 29)
regarding the validity of the ISO standard as follows:

dents who smoked cigarettes on one or more days in the
30 days preceding the survey. The findings of the study

will be disseminated in the following ways:

1 Tar, nicotine, and CO numerical ratings based upon cur­
rent ISO/FTC methods and presented on cigarette pack­
ages and in advertising as single numerical values are

— research report;

misleading and should not be displayed.

— fact sheets with national and provincial results;
— posters at the national and provincial launches;

b All misleading health and exposure claims should be
banned.

— national launch of the findings;
c The ban should apply to packaging, brand names,

— provincial workshops;

advertising and other promotional activities

— press releases;
d Banned terms should include light, ultra-light, mild and

— journal articles;
— conference presentations.

low tar, and may be extended to other misleading terms.
The ban should include not only misleading terms and

claims but also, names, trademarks, imagery and other

means conveying the impression that the product pro­
vides a health benefit.

World Health Organization

Department of Health. The cigarette laboratory is SANAS

tobacco-related questions be included in other studies that

(South Africa National Accreditation System) accredited.

are conducted nationally on an annual basis.
One of the strengths of surveillance in SA is the active

Conclusions

participation of the government from the inception of the

research project. This ensures ownership of the research
Even though South Africa has a short history of tobacco

process and the findings of the study. The SADHS and

control with few dedicated tobacco control researchers

GYTS provide good examples of the dissemination of

and limited resources, several mechanisms have been set

user-friendly manner. Both these studies are being used by

tobacco-related morbidity and mortality.

the government (as a partner and funder in the research

Considering that South Africa is a developing country with

process), and by the researchers themselves, to trans­

limited resources to allocate to tobacco-specific surveil­

late the research findings into programmes and policies.

lance, the Demographic and Health Survey can fulfil this

However greater emphasis, and perhaps skills as well as

role adequately. Even though a standardized WHO ques­

resources, are needed to disseminate the research findings

tionnaire was used to measure tobacco use in this study,

to a wider audience and to develop effective programmes.

problems of literacy and numeracy limited the usefulness

It must be noted that there usually is lack of continuity

of the questions on tobacco. It is therefore recommended

in the research process after the dissemination stage, as

that questionnaires be adapted, tested and validated for

the researchers are not necessarily responsible, capable or

the local context. The SADHS makes it possible to see the

funded to develop programmes.

relationship between tobacco use and tobacco related

The Cancer Registry has a formidable infrastructure for

morbidity as well as between co-risk factors such as expo­

collecting tobacco-related morbidity information. In order

sure and occupational hazards such as dust and fumes.

to streamline the process, information needs to be collect­

An innovative and cost-effective method was employed in

ed on a standardized form that is shaped by international

conducting the GYTS and YRBS in the same schools but with

initiatives, at prescribed intervals; it should include data

different classes. This decreases the amount of time required

from many more public and private laboratories.

in the school and is a methodology that suits the needs of

Including a tobacco question on the Death Notification

both the school community and survey administrators. The

form is an innovative and cost-effective way of measuring

tobacco questions were standardized across both studies.

tobacco-related mortality. Tapping into existing surveil­

This allows for comparison between the studies increasing

lance structures is particularly useful in countries where

the sample size from 15000 in each study to 30000 across

financial resources are limited. However, the question

both studies. If both these studies are repeated on a 3 year

needs to be piloted so that it yields useful information.

cycle, then South Africa will have an effective system in

The Cancer Registry and Death Notification System could

place to monitor trends in adolescent behaviour.

maximize their usefulness by identifying deaths caused by

The National Department of Health should be applauded

histologically verified tobacco-induced cancers.

for using research as a basis to monitor and evaluate the

Standardization of questions, including definitions used, is

implementation of the smoke-free policy in formal and

of paramount importance for local and international com­

informal restaurants and pubs. Other aspects of the leg­

parability of studies, particularly when these show shifts in

islation that could be monitored include compliance with

trends of tobacco use.

smoke-free policies in the work place and underage sales

of tobacco.

8

research findings to government and other agencies in a

up to monitor and evaluate tobacco prevalence as well as

In South Africa, the tobacco control policy was developed
and partially implemented before tobacco-specific research

It is unfortunate that the biannual Household Survey that

was conducted. Countries lacking tobacco research or

included tobacco-related questions was discontinued as

research capacity could also follow this route. Ideally,

this was an inexpensive surveillance tool to monitor trends

local research findings should be the motivation for policy

in tobacco use on a yearly basis. This survey could have

development. Once the policy is in place, research should

complemented the SADHS by monitoring tobacco use

continue in order to monitor and evaluate the implemen­

over a shorter period than the 5 year intervals at which

tation of the policy and guide amendments to the policy

the SADHS is conducted. It is recommended that the

and programmes.

The Surveillance and Monitoring of Tobacco Control in South Africa

References

14.

0

Sitas F, Madhoo J. Wessie J. Cancer in South Africa, 1993-

1995. National Cancer Registry of South Africa, South

1.

Statistics South Africa. October household survey. Statistical

African Institute for Medical Research, 1998.

Release PO317, July 2000; available from URL: http.H/C/
Windows/Desktop/OhsCurrent/P0317.htm

15.

Sitas F. Personal communication. MRC/CANSA/SAIMR/WITS
Cancer Epidemiology Research Group, 16 September 2002.

2.

Wilkens N, ed. Poverty and inequality in South Africa.

Summary Report, 1998; available from URL:

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Vital Registration Reports. Tobacco attributed mortality in

black and mixed race South Africans; available from URL:
http://www.polity.org.za/govdocs/reports/poverty.html
3.

Swart D, Reddy P. Strengthening comprehensive tobacco
control policy development in South Africa using political

http://196.36.153.56/doh/nhis/vital/docs/tobacco.html

17.

4

Tobacco Products Control Act No. 83, 1993. Government

18.

Tobacco Products Amendment Act No. 12, 1999; available

19.

1999Zact12.html

20.

21.

414, No. 20687, 1999.

7.

Reddy P, Meyer-Weitz A, Yach D. Smoking status, knowl­

Vital Registration Infrastructure Initiative; available from URL:
http://196.36.153.56/doh/nhis/vital/docs/vregistrar.html

Tobacco Products Amendment Act, 1999 Regulations.
Government Gazette, Regulation Gazette No. 6689, Vol.

Van Walbeek C. Personal communication. School of

Economics, University of Cape Town, 21 September 2002.

from URL: http://196.36.153.56/doh/docs/legislation/acts/

6.

South African Advertising Research Foundation; available

from URL: http://www.saarf.co.za//allabouthtm

Gazette, No. 14916, Vol. 337, 1993.

5.

Sitas F. Personal communication. MRC/CANSA/SAIMR/WITS
Cancer Epidemiology Research Group, 25 September 2002.

mapping. Medical Research Council, 1998.

Steyn K. Personal communication. Chronic Diseases of

Lifestyle, Medical Research Council, 18 September 2002.

22.

edge of health effects and attitudes towards tobacco control

Dr D Bradshaw. Personal communication. Burden of Disease,

Medical Research Council, 18 September 2002.

in South Africa. South African Medical Journal, 1996, 86(11):

1389-93.

23.

Guidelines for controlling and monitoring the tobacco epi­
demic. Geneva, World Health Organization, 1998.

8.

Reddy P, Meyer-Weitz A, Levine J. Smoking prevalence
among adult smokers in South Africa. National Health

24.

of 1999. Department of Health, 2001.

Research Council, 1998 (unpublished report).
9.

Meyer-Weitz A, Reddy P, Levine J. The impact of South

Specifications for a study to determine levels of compliance

with the Tobacco Products Control Amendment Act No. 12

Promotion Research and Development Office, Medical

25.

Mthembu Z. Personal communication. Directorate of Health

Africa's first tobacco control legislation on adults' smok­

Promotion, National Department of Health, 19 September

ing status: February 1995 to November 1998 (submitted in

2002.

2000).
26.
10.

South Africa Demographic and Health Survey 1998. Full

Reddy P. Application for the tender to conduct a National

Youth Risk Behaviour Survey in South Africa. Medical

Report. Department of Health, Medical Research Council,

Research Council, 2001.

2002.
27.

11.

Steyn K, Bradshaw D, Norman R et al. Tobacco use in South

Government gazette No. 16111 of 2 December 1994,
Department of Health, Annex 3, page 26.

Africans during 1998: the first Demographic and Health
Survey. Journal of Cardiovascular Risk, 2002, 9:161-170.

28.

South African Bureau of Standards: Test house; available
from URL: http://www.sabs-testing.de/

12.

Van Walbeeck C. Recent trends in smoking prevalence in

South Africa. The economics of tobacco control in South
Africa. 2002 (unpublished book).

29.

SACTob recommendations on health claims derived from
ISO/FTC method to measure cigarette yield. Geneva, World

Health Organization (WHO/NMH/TFI/02.02).
13.

Swart D, Reddy P. Pitt B et al. The prevalence and determi­
nants of tobacco use among grade 8-10 learners in South

Africa. A Global Youth School-based Survey. Medical

Research Council, 2001.

World Health Organization

Acknowledgements
The authors would like to thank Dr D. Bradshaw, Ms L.
Mohlasela, Ms Z. Mthembu, Dr Yussuf Saloojee, Prof F. Sitas,

Dr K. Steyn and Mr C. Van Walbeeck for having given interviews
and provided relevant documentation.

r

10

Tools for Advancing Tobacco Control

in XXIst century:

Success stories and lessons learned

Outils pour poursuivre la lutte antitabac
au XXPsiecle:

Experiences concluantes
et nouveaux enseignements

Effective Access to Tobacco ““
Dependence
Treatment

Effective Access to Tobacco Dependence
Treatment, New Zealand

Tobacco Free Initiative would like to thank
the Centers for Disease Control and Prevention (CDC), Atlanta, USA

fortheir generous support for this project.

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Printed in World Health Organization, Geneva

New Zealand:
Effective Access to Tobacco

Dependence Treatment
Liz Price and

Matthew Allen
Allen & Clarke Policy and Regulatory Specialists

Limited

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Tobacco Free Initiative Headquarters would like to thank the Regional Offices

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New Zealand: Effective Access to Tobacco Dependence Treatment

Introduction

The Quit Group and private-sector services that receive

At the beginning of 1998 New Zealand lacked tobac­

Government funded.

no Government funding. Other services may be partially
co dependence treatments. Only a small amount of
Government funding was committed to smoking cessation

The Quit Group

programmes and it was difficult for many people to find
help in quitting. Most of the cessation programmes availa­

The Quit Group is contracted to provide Government-

ble were offered by the private sector. These programmes

funded whole-population smoking cessation services

were few in number, often expensive and tended to target

in New Zealand. Programmes it manages include the

white, middle-class smokers. There was little help available

Quitline, the Quit Campaign (which includes the Every

for Maori - New Zealand's indigenous population - 50%

cigarette is doing you damage, and It's about whanau

of whom smoke.
In addition, broader tobacco control measures that would

multimedia campaigns), the Health Provider NRT Exchange
Card Programme, and the Quit for our kids programme.

indirectly support smoking cessation were lacking. Health
warnings were weak, smoke-free environments largely
confined to offices and public transport, and there had not

been a significant increase in tobacco excise since 1991.

For several years the tobacco control community in

The Quit Campaign
The Quit Campaign is a mass communications campaign

and a national telephone Quitline. The Quitline was first
piloted in the Waikato/Bay of Plenty region between

New Zealand lobbied for a smoking cessation media

September 1998 and April 1999 by a partnership of three

campaign and the provision of help for individuals. The

organizations: the Health Sponsorship Council, Cancer

Government listened. In 2003, New Zealand has one of

Society of New Zealand and Te Hotu Manawa Maori. The

the most advanced mixes of population-level smoking

region chosen for the pilot had a smoker population base

cessation initiatives in the world. In five years it has gone

of around 100000, approximately 30% of whom were

from almost zero Government funding of smoking ces­

Maori. 'Threat appeal' television commercials adapted from

sation programmes, to funding of around NZ$ 13 million

the Australian National Tobacco Campaign were screened.

per annum. This is nearly 50% of the total New Zealand

These commercials showed the consequences of smoking

tobacco control budget.1 The initiatives include a national

in graphic detail - images of fatty aortas and rotting lungs,

Quitline, subsidized nicotine replacement therapy (NRT),

for example. Smokers were given the freephone Quitline

Maori-focused quit services including quit support and

number and urged to call for help and advice. Nine thou­

NRT for Maori women and their whanau (families), and a

sand calls were received during the six-month pilot.

hospital-based quit service for inpatients and their families.

In 1999, Government funding was secured for the

Broader measures supporting smoking cessation are also

Quitline, and it was launched nationally in May that

in place or planned, including stronger health warnings, a

year. A multimedia campaign promoting the service was

ban on point-of-sale advertising, legislation that proposes

launched two months later. The Australian television cam­

to ban or severely restrict smoking in workplaces, and sig­

paign Every cigarette is doing you damage was continued,

nificant excise increases in 1998 and 2000.

and an empathetic Quitline advertisement was also shown.

Description of the policy interventions
New Zealand’s smoking cessation landscape is made up of

The campaign was particularly designed to be effective
for New Zealand's Maori population. A number of Maori

quit advisers were employed, and culturally appropriate

a number of varied initiatives, targeting different groups.

Quitline services and quit materials were developed.

It includes Government-funded organizations such as

The Quitline and the multimedia campaigns now receive

around NZ$ 3 million annually.

Subsidized NRT*
In November 2000, the cessation landscape in New

Zealand changed significantly with the introduction

3

World Health Organization

Figure 1
Incoming and Outgoing Quitline Calls - July 2000 to June 2001

of Government-subsidized nicotine patches and gum.

smokers, and those who have angina, palpitations or who

Government funding of NZS 6.18 million per annum had

have suffered a heart attack are asked to talk to their

been allocated to this project earlier in the year. This meant
that the price of nicotine patches or gum for smokers could

general practitioner (GP) about their suitability for nicotine

be greatly reduced - from a maximum of around NZS 136

Around 55000 people a year have registered with the

to NZS 10 for a four-week supply. Since then, the price
of subsidized patches and gum has been further reduced
to NZS 5 for the first month and NZ$ 10 for the second

patches and gum (1).

Quitline since subsidized NRT was made available in
2000.2 This represents 7% of the smoker population in
New Zealand registering each year.

month.

Initially public demand was overwhelming, peaking at
When callers contact the Quitline they are connected to a
call centre. An operator offers the caller a choice of receiv­
ing a pack of quit information or being put through to a
quit adviser. Callers who meet specific criteria are issued

with a nicotine patches or gum 'exchange card' which

they can redeem at participating pharmacies (see below).

Research shows that heavier smokers are more responsive

to NRT, and therefore as a general rule only those who
smoke more than 10 cigarettes a day are eligible for the
subsidized patches and gum. Pregnant or breastfeeding

70000 calls to the Quitline in the first month.34A number
of major changes to the Quitline were required to cater

for the huge numbers. These included moving to bigger
premises, increasing staff numbers, and greatly reduc­

ing advertising and public relations activity over several
months until call levels dropped. Quitline advisers also

make outgoing calls (known as call-backs) offering ongo­
ing support and advice to people undertaking a quit
attempt. Call-backs had to be reduced for a time after the
introduction of the subsidized patches and gum owing to

the volume of incoming calls.
2 Personal communication, the Quit group, August 2002.
3 This figure includes 'hang-ups' and also those people call­

ing more than once while the Quitline initially struggled to
cope with the number of people calling.

4

Health Provider Exchange Card
Programme
Another initiative, the NRT Health Provider Exchange Card

4 Personal communication, Steeve Cook, Coordinator of the

Programme, allows individuals and groups with an interest

Health Provider Exchange Card Programme, the Quitline,

in smoking cessation to distribute exchange cards directly

August 2002.

to their clients. Exchange card recipients can then redeem

the cards at participating pharmacies and receive subsidized

New Zealand: Effective Access to Tobacco Dependence Treatment

Type of NRT

Distribution

Price, subsidized

Approximate price

(on presentation of

unsubsidized

Exchange Card)’

Patches

General sales medicine

NZ$ 5 for four-week supply

NZ$ 71.20 for

(can be obtained from any

(5 mg, 10 mg and 15 mg)

four-week supply

outlet)
Gum

General sales medicine

(10 mg)

NZ$ 5 for four-week supply

NZ$ 136.80 for

(2 mg and

four-week supply

4 mg)

Nasal spray

Prescription medicine (can

Not subsidized

(4 mg)

NZ$ 43.71 (10 mg/ml) for
one- to two-week supply

only be obtained on a doc­

tor's prescription)

Nicotine inhaler

Pharmacist-only medicine

Not subsidized

NZ$ 43.37 (10 mg starter

(can only be obtained from

pack and refills) for two- to

a pharmacist, but a pre­

four-day supply

scription is not needed)
4 Source: National Health Committee (5).

nicotine patches and gum. All providers who wish to be

Quit for our kids programme

part of this programme must be registered with The Quit

Group, which oversees the programme. As of August 2002,
around 250 health providers were registered with the serv­

Quit for our kids is a national programme for hospital

patients, established in 2000. It aims to help parents and

ice.4 They included independent practitioner associations

caregivers of children who are having hospital treatment

representing several hundred GPs, individual GPs, main­

to quit smoking. The programme operates in nine hospitals

stream cessation providers (serving the general population

in New Zealand, with a focus on areas with a high need

rather than a specific population or ethnic group), and

for smoking cessation services. The quit coaches working

Maori health providers, more Than 40000 exchange cards

have now been issued through the programme.
To guide the programme, The Quit Group has established

an advisory committee consisting of professionals from rel­
evant fields, to assist with policy decisions.

in each hospital provide advice, support and NRT to those
parents and caregivers who want to quit. Quit coaches are

also able to distribute nicotine patches and gum as part of

the treatment plan. The programme will be promoted in
five new hospitals in 2002. The Quit Group coordinates
this programme, provides training and manages the pro­

gramme evaluation.

It's about whanau

Aukati Kai Paipa
A media initiative designed by Maori to appeal to Maori
smokers, the It's about whanau campaign was launched

Aukati Kai Paipa is currently delivered by over 30 Maori

in August 2001. The campaign aims to motivate Maori

health providers. The programme offers Maori women and

smokers to see the benefits of quitting, not only for them­

their whanau free cessation services. Those referred are

selves but also for their family and friends. Maori are the

assessed for their readiness to quit (2). Participants initially

priority group for the campaign because of the dispropor­

undertake an intensive eight-week programme using NRT

tionately high number who smoke and their high rates of

and motivational counselling delivered through a minimum

smoking-related disease.

of seven follow-up visits. After the initial eight-week peri­

The campaign uses Maori role models to give a positive

od, participants receive further follow-up visits at intervals
of three, six and 12 months.

message about the benefits of quitting. It includes national

television commercials and magazine and radio advertis­
ing, supported by public relations activities.

0

World Health Organization

The programme has a focus on holistic health. Te Hotu
Manawa Maori coordinates, trains, assists and advises the

Smoking cessation services
for pregnant women

network of Aukati Kai Paipa services.
Specific cessation services are available to pregnant

Guidelines for smoking cessation

women. These services are often associated with maternity

The Government-funded Guidelines for smoking cessation

for example GPs, midwives etc. Smoking cessation training

hospitals, and can be accessed through maternity carers,

document was developed by a team of smoking cessa­

for health professionals working with pregnant women is

tion experts in 1999 and updated in 2002. The guidelines

also available. New Zealand's smoking cessation guide­

are designed for smoking cessation providers in assisting

lines (6) advise that NRT should be considered when a

clients with smoking cessation. The document is based on

pregnant/lactating woman is unable to quit, and when the

comprehensive literature reviews and background informa­

likelihood of quitting, with its potential benefits, outweighs

tion on smoking cessation.

the risks of NRT and potential continued smoking.

Training in smoking cessation, following the steps set out

Smoking cessation services offered by
GPs and GP groups

in the guidelines, is available from several nongovernmen­

tal organizations (NGOs).

An increasing number of GPs offer smoking cessation serv­

NRT reclassified as general
sales medicine
Nicotine patches and gum were reclassified as general

ices to their patients, often in conjunction with subsidized
nicotine patches and gum.

Other smoking cessation programmes

sales medicine (able to be sold ‘over the counter') in

August 2000. Previously only pharmacies or smoking ces­

Smoking cessation services are also offered by a number

sation clinics run by a health professional could sell the

of other individuals and groups. Cessation help can be

products (3).
Nicotine nasal sprays remain a prescription medicine, while
nicotine inhalers are a pharmacist-only medicine (4). Nasal

sprays and nicotine inhalers were not made available over
the counter as it was felt that these products had a greater

potential for abuse than patches and gum. It was also felt
that sprays and inhalers were better suited to those who
were more severely addicted and would benefit from a

greater input from a medical professional.

Quit & Win
A Quit & Win smoking cessation competition was piloted

in 2001, and extended to five health regions in 2002. The
Government-funded competition requires entrants to stop

smoking for the month of May to be eligible for local,
national and international prizes.

Quit and Win is coordinated by the Health Sponsorship

provided in a number of ways - from group-support ses­
sions, counselling and the provision of nicotine replace­

ment therapy, to hypnotherapy and acupuncture. Many of
these services are offered by the private sector, although

some may be partially Government funded. In addition,
some of these services deliver subsidized NRT through the
Health Provider Exchange Card Programme administered

by The Quit Group.

Bupropion (Zyban) and nortriptyline
Bupropion and nortriptyline are available on a doctor’s
prescription. Following the recording of over 200 adverse
reactions to bupropion in New Zealand, the Medicines'

Adverse Reactions Committee advised in September 2001

that it be prescribed only after a person has unsuccess­
fully tried other stop smoking treatments (7). Bupropion is
not publicly subsidized and a seven-week course will cost
around NZ$ 300 (8).

Council, a Government agency. Nearly 1800 people

entered the 2002 competition, representing 1.8% of
the Quit & Win region's smoking population. This result

6

5

Personal communication, Jeremy Lambert, Health

was well in excess of the 1.25% international participa­

Sponsorship Council, July 2002. Also in Health

tion rate. The competition is currently being evaluated to

Sponsorship Council Chat Sheet, March 2002.

determine quit rates.5

New Zealand: Effective Access to Tobacco Dependence Treatment

Nortriptyline is not registered in New Zealand for use

Steps of implementation

as a smoking cessation aid, but can be prescribed for
this purpose. It is fully subsidized and as such the New

In 1997 New Zealand's inaugural National Smokefree

Zealand Smoking cessation guidelines recommend that it

Conference was held, bringing together for the first time a

be considered after a person has unsuccessfully tried other

large number of tobacco control workers. The conference

treatments, in particular for people who cannot afford

endorsed a strong call to Government for the provision

bupropion.

of smoking cessation services. In the same year a national

Auahi Kore (smoke-free) conference was held for Maori

Other tobacco control initiatives
undertaken during this period

tobacco control workers. Maori advocacy group Apaarangi

Tautoko Auahi Kore (ATAK) was established as a result of
the conference. Maori had a coordinated voice, and were

The period 1998-2002 was a busy one for tobacco control

calling for funding to help their people stop smoking.

in New Zealand. Smoking cessation initiatives included:

Ongoing

Promotion of smoke-free environments in a variety of settings by the Government agency, the
Health Sponsorship Council.

Ongoing

Enforcement of the Smoke-free Environments Act 1990, and promotion of smoke-free messages
by Government-funded public health services.

May 1998

Tobacco excise increase of 50 cents plus tax on a pack of 20 cigarettes, and equivalent for other
tobacco products.

June 1998

Cessation of the requirement for replacement sponsorship by the government of previously tobac­
co-industry sponsored events.

June 1998

National conference: Smokefree Towards 2000.

December 1998

Tobacco advertising at point of sale ceases.

July 1999

Smoke-free Environments (Enhanced Protection) Amendment Bill introduced to Parliament.
Proposals include a ban on smoking in educational institutions except tertiary, further restrictions
on the display of tobacco products, further restrictions on smoking in workplaces, and strengthen­
ing of penalties for retailers convicted of selling tobacco to minors.

September 1999

Auahi Kore conference.

January 2000

Stronger health warnings and constituent information on tobacco packets.

April 2000

National Smokefree Conference.

May 2000

Tobacco tax increases of NZ$ 1 on pack of 20 cigarettes, and equivalent for other tobacco prod­
ucts.

May 2001

World Smokefree Day focus is Lets Clear the Air. Television commercials promoting smoke-free
homes and bars are aired.

June 2001

Supplementary Order Paper to the Smoke-free Environments (Enhanced Protection) Amendment
Bill introduced to Parliament. Proposals include further restrictions on smoking in restaurants,
clubs and casinos, and restrictions on smoking in bars, a ban on the supply of tobacco products to
minors, and a ban on self-service vending machines. Health groups push for total ban on smoking
in restaurants, bars, clubs and casinos.

October 2001_________________ Auahi Kore conference.
June 2001_______________ Consultation on the draft Tobacco Control Research Strategy initiated.

May 2002____________________ New Zealand's World Smokefree Day focus Is again Let's Clear the Air.
Invercargill woman Janice Pou initiates legal action against British American Tobacco and W D &
H O Wills claiming that they continued to manufacture, supply and advertise cigarettes that were
addictive and gave her cancer.

June 2002

Let's Clear the Air television campaign re-launched by The Quit Group.

August 2002
September 2002

___________

National Smoke-free Conference.

New Zealand: Effective Access to Tobacco Dependence Treatment

for those aged 15 years and over was 26% in 1998 and

25% in 2001 (10).

Maori smoking prevalence has remained static over this

Subsidized NRT

Quit rate after three months: around
44%6

Aukati Kai Paipa

Quit rate appears to be significantly

time, hovering at 49-51 %. This is unacceptably high when

higher at 12 months (23%)7 than

compared with a non-Maori smoking rate of 21%. The

the rate for those not on the pro­

lack of change may be because Maori-focused tobacco

gramme (12.5%)

control programmes have only been delivered over the

past few years, while mainstream programmes (although

not necessarily quit programmes) have been available for

Biological correlates of self-reported quit rates have not

been undertaken in the subsidized NRT and Aukati Kai

decades. Maori smoking rates over the next five years will

Paipa programmes. A literature review into the value of

be a telling indication of whether the new, targeted cessa­

validation of self-reported smoking status was carried out

tion initiatives are having an effect.
Tobacco consumption decreased from 1377 cigarettes per
adult in 1998 to 1139 cigarettes per adult in 2001. Over

the past 10 years, the average number of cigarettes con­
sumed per adult has decreased by more than one-third

(11). The accelerated rate of decline in consumption in

recently by The Quit Group. Many of the papers reviewed
found that self-response of smoking status is a good indi­

cator of actual smoking status. Where underreporting does
occur, there is no statistically significant difference between

self-reported and validated smoking status, meaning that
the overall conclusions of the studies are not affected (14).

2000-2001 is likely to be mainly attributable to the tobac­
co excise increase of NZ$ 1 in May 2000.
A comparison with other OECD countries suggests that

6

This is a conservative measure. A simpler measure of 'Quit

the New Zealand adult smoking rate is in the medium

= not smoked for two days but may have had occasional

to low category (12), while New Zealand has one of the

puffs’, would give a point prevalence quit rate of 58%

lowest tobacco product consumption rates of any OECD
country (13).

after three months.
This is also a conservative measure. The simpler measure

Many of New Zealand’s cessation initiatives began rela­

of ‘Quit = not smoked for two days but may have had

tively recently and are still being evaluated. Some interim

occasional puffs', would give a point prevalence quit rate

results are available from the subsidized NRT and Aukati

of 30% after 12 months.

Kai Paipa programmes.

Figure 2
Tobacco Products Released for Consumption

World Health Organization

Youth smoking rates
Smoking among New Zealand fourth-form students (14

well. Pharmacies are now involved in the programme as
dispensers of NRT only.

Impact on pharmaceutical companies

and 15 year-olds) rose steeply from 1992, but began to

males and females had returned to levels comparable with

It was no surprise that the subsidized NRT programme
significantly altered market forces with respect to the

1992. In 2001, 16.3% of males and 22% of females 14 to

sale of stop smoking products. Sales of the subsidized

level off in the late 1990s. In 2001, smoking rates for both

15 years of age smoked at least weekly (75).

products rose, while sales of non-subsidized products fell.

An exception occurred soon after the introduction of the

Other impacts of the intervention

subsidized Government programme, when the Quitline
was having difficulty coping with demand. Sales of some

Budget pressure

non-subsidized stop smoking products were relatively

The NZS 6.18 million allocated to subsidized nicotine

the subsidized programme purchased full-price products. A

high, as people motivated to quit by the publicity around

patches and gum initially appeared to be in danger of
being exceeded, because of huge demand. However, this
did not turn out to be the case, and the budget appears to

match demand well.

general increase in awareness of smoking cessation issues
also contributed.
Volumes of all NRT products dispensed - subsidized and

unsubsidized - peaked in May 2001, and have since
Rise in cessation advertising

Advertising of cessation services and products has
increased over the past three years. Some providers of

smoking cessation services promoted subsidized NRT,

while others used the increased profile of NRT to promote
non-subsidized and in some cases non-nicotine-based
products. The various cessation initiatives resulted in

tobacco dependence treatment becoming a much more
prominent health issue than previously.
Impact on pharmacies

declined. Unsubsidized stop smoking products are still
selling, but at lower levels. Interestingly, most impact has

been on sales of nicotine patches - nicotine gum sales
have not been affected to the same extent.8

Conclusion
Several key factors contributed to New Zealand's trans­

formation from a country that offered little in the way of

smoking cessation help to one that has a comprehensive
mix of initiatives. Central to the change was strong and

persistent advocacy from the tobacco control community.
The subsidized NRT initiative has had a significant effect

Other key factors were proactive policy analysts and a

on pharmacies, as they are the point of redemption for

supportive government. Tax increases also played a part in

exchange cards. Despite initial plans to consider other out­

motivating smokers to call for cessation help. Their mes­

lets, such as supermarkets and service stations, as possible

sage to the Government was that it was unfair to increase

redemption points, pharmacies remain the only type of

the price of tobacco products without providing cessation

outlet involved.

help. This message was picked up and amplified by health
groups.

Initially pharmacies also had the ability to be exchange

card providers themselves. They could distribute as well

New Zealand can be proud of its activities. First, the wide

as redeem the cards, provided they met certain criteria.

reach and variety offered by its cessation initiatives. The

Around 80 pharmacies joined the scheme as exchange

national Quitline, for example, has offered quit advice and

card providers.

support to nearly 140000 New Zealanders over the past

However, in September 2001, the Ministry of Health

four years, making it one of the busiest Quitlines in the

withdrew this right from pharmacies, citing possible con­

world. Nearly 190000 exchange cards have been distribut­

flict of interest issues. The Ministry stated that pharma­

ed. While the results of a comprehensive evaluation of the

cies, as suppliers of NRT products, potentially stood "to

make a small financial gain when they exchange cards for
the product" (76). Many pharmacists were critical of the

10

ministry's decision, believing that the system was working

8 Personal communications with New Zealand pharmaceuti­
cal companies, August 2002.

New Zealand: Effective Access to Tobacco Dependence Treatment

Quitline and subsidized NRT are not yet available, early

4.

figures are promising. For those who prefer an individual
or small-group approach, subsidized nicotine patches and
gum, along with quit support and advice, can be obtained
from health providers spread throughout the country.

Second, New Zealand's cessation initiatives are targeted

Guidelines for smoking cessation. Wellington, National

Health Committee, 2002.

5.

Ibid.

6.

Ibid.

7.

Changes to the way Zyban is prescribed. Ministry of Health

at groups with higher smoking rates, particularly Maori.

media release of 26 September 2001, available at web site

The Aukati Kai Paipa, and It's about whanau initiatives,

http://www.ndp.govt.nz/media/moh26sept2001.html.

for example, have been developed by Maori for Maori.
Even the mainstream initiatives, such as the Quitline, have

8.

These cessation initiatives have been complemented

Figures from GlaxoSmithKline web site, available at http:

//gsk.co.nz/Zyban/thefacts/cost-html.asp?productlD=6

Maori as a primary audience.
9.

Tobacco facts. Public health intelligence occasional report no

2. Wellington, Ministry of Health, 2002 (available at web site

by New Zealand's other tobacco control programmes.

http://www. moh.govtnz/moh. nsf/wpgJndex/Publications-

Tobacco tax increases, smoke-free environments, and

Index).

health promotion initiatives have all created a demand for

stop smoking services.

10.

One lesson learnt was the unanticipated demand for sub­

11.

Ibid.

12.

Ibid.

sidized NRT. The Quitline was overwhelmed, and delivery

of exchange cards was slow for several months. More time
to establish this initiative would have enabled demand to

13.

be better gauged and catered for. The demand, however,
proves that many smokers are motivated to quit, and the
availability of reduced-cost NRT can act as a catalyst.

There is no apparent reason why New Zealand's pro­

gramme could not be adapted to other countries if suf­
ficient funding was available. Strong advocacy is needed

to put pressure on governments to provide this funding.
Once the funding is available, care should be taken to

Ibid.

Tobacco Statistics 2000. Wellington, Cancer Society of New
Zealand, 2000.

14.

Woodward Z. Validation of self-reported smoking status.

Literature review for the Quitline, December 2002.
75. Tobacco facts. Public health intelligence occasional report

no. 2. Wellington, Ministry of Health, 2002.
16. NRT programme: pharmacists no longer required. Pharmacy
Today, September 2001.

target initiatives at those with the highest smoking rates.
Services and resources should be developed with the input

Acknowledgements

of those in the target audience, to ensure that they are
appropriate for that group. Initiatives should also be care­

The author would like to thank the following people for providing

fully evaluated to ensure that they are reaching objectives

information for, and comments on, this paper:

and represent value for money. Positive results from care­

lain Potter - Health Sponsorship Council

fully researched, developed, tested and evaluated cessa­

tion initiatives in one country enable tobacco control advo­

Shane Bradbrook - ATAK

cates internationally to argue for similar programmes.

Teresa Taylor and Sue Taylor - Te Hotu Manawa Maori

References__________________________

Helen Glasgow, Jane Mills, Belinda McLean, Michele Grigg and

Ben Weston - The Quit Group
7

Guidelines for smoking cessation. Wellington, National
Health Committee, 2002.

2.

3

Ibid.
Quit smoking products on shop shelves soon. Ministry of

Health media release of 25 August 2000, available at web

site http://www.ndp.govt.nz/media/moh25aug2000 . html.

Chas McCarthy, Chris Laurenson, John Stribling, Kate Rockpool,

Candace Bagnall - Ministry of Health

Anne Dowden - Business Research Centre

Tools for Advancing Tobacco Control

in XXIs* century:

Success stories and lessons learned

Outils pour poursoivre la lutte antitabac
au XXPsiecle:

Experiences concluantes
et nouveaux enseignements

Advertising and
Promotion
Bans

Thailand Country Report on Tobacco Advertising
and Promotion Bans.

WHO/NMH/TFI/TFC/03.9

Tobacco Free Initiative would like to thank

the Centers for Disease Control and Prevention (CDC), Atlanta, USA

for their generous support for this project.

© World Health Organization 2003
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Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

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and correct and shall not be liable for any damages incurred as a result of its use.

The named authors alone are responsible for the views expressed in this publication.

Printed in World Health Organization, Geneva.

Thailand Country Report on Tobacco

Advertising and Promotion Bans
Hathai Chitanondh
President, Thailand Health Promotion Institute

World Health Organization

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

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Thailand Country Report on Tobacco Advertising and Promotion Bans

Introduction

For the past two decades, the total number of smokers has

Countrywide household surveys by the National Statistical

9 676 700 in 1981 to 10 551 300 in 2001. Smoking prev­

Office have been the main source of information support

alence declined from 35.2% in 1981 to 22.5% in 2001.

for tobacco control in Thailand. The first, second and third

Male and female smoking rates fell in this period from

surveys were carried out in 1976, 1981 and 1986 (five

63.19% to 42.92%, and from 5.39% to 2.36% respec­

year intervals). Thereafter the surveys were carried out

tively. Annual adult per capita cigarette consumption has

every two years.

also been decreasing, from 1087 in 1995 to 798 in 2000.

risen, presumably as a result of the rise in population, from

Figure 1
Number of Smokers and Smoking Prevalence of Population. Both Sexes, 15 Years and Over, 1981-2001

| Number of smokers

I

Cj

Male prevalence
Prevalence of both sexes
Female prevalence

Source: Calculated from reports of The National Statistical Office

Development of policy:
Chronology
26 April 1988 - The Cabinet approved tobacco control measures, including a ban on advertising, proposed by the

Ministry of Public Health (MOPH). This resolution was forwarded to all ministries to be put into practice.

20 December 1988 - the Thailand Tobacco Monopoly (TTM) complained to the Ministry of Finance, its supervisor,

that after the April cabinet resolution the TTM had ceased its promotional activities, while foreign cigarettes, though
not allowed to be sold legally, continued to advertise in the printed media and on outdoor billboards. The cabinet
therefore ordered the Consumer Protection Board (CPB) to pass a regulation prohibiting tobacco advertising.
10 February 1989 - The Advertising Committee of the CPB made an announcement, published in the Royal Cazette,

that cigarettes are under labelling control, thus cannot be advertised, pursuant to the Consumers Protection Act 1979.

4 August 1992 - The Tobacco Product Control Act (TPCA) 1992 became effective.
3

World Health Organization

Information about tobacco-related morbidity and mortality

has been fragmented owing to the lack of relevant stud­
ies and surveys. Among cancers of various organs, lung

cancer was the second most common during 1988-1991.

The age-standardized incidence rate of lung cancer among

women in the Northern region is 37.4 per 100000 - con­
sidered to be a high world indicator.

the packaging of tobacco products for exchange or
redemption therefor;

Section 7: No person shall be allowed to distribute tobacco
products as a sample of tobacco products so as to prolif­
erate such tobacco products or to persuade the public to
consume such tobacco products except for a customary

gift;
The advertising ban under the Consumers Protection

Act 1979, which became effective on 10 February 1989,

was enforced by the office of the CPB which has a wide

responsibility in the area of consumer protection. Officials
of the CPB were not knowledgeable about tobacco pro­
motional tactics and did not enforce the law as regards
the ban on tobacco advertising. The secretary of the

National Committee of Control of Tobacco Use (NCCTU)
had to request prosecution in every case of wrongdoing.

Section 8: No person shall be allowed to advertise tobacco
products or expose the name or brand of tobacco prod­
ucts in the printed media, via radio broadcast, television

or anywhere else which may be used for advertising pur­
poses, or to use the name or brand of tobacco products in

shows, games, services or any other activity the objective

of which is to let the public understand that the name or
brand belongs to tobacco products.

Therefore the NCCTU secretary, who was the chairman of

The provisions of paragraph one do not apply to live

the tobacco control law drafting committee, incorporated

broadcasts from abroad, via radio or television, and the

the advertising ban in the newly drafted TPCA. Thus the

advertisement of tobacco products in printed media print­

new law would be under the responsibility of the MOPH,

ed outside the Kingdom not specifically for disposal in the

which has more knowledgeable officials. After the TPCA

became effective on 4 August 1992, the announcement of
the CPB Advertising Committee became nullified.
The Tobacco Products Control Act 1992

In this Act, sections relevant to bans on advertising and
promotion are as follows:

Section 3: "Advertising" means an act undertaken by any

means to allow the public to see, hear, or know a state­
ment for commercial interest;
Section 4: No person shall be allowed to dispose of, sell,
exchange or give tobacco products to a person when it
is known to the former that the buyer or receiver has not

attained eighteen full years of age;

Section 5: No person shall be allowed to sell tobacco prod­
ucts through vending machines;

Section 6: No person shall be allowed to do any of the fol­
lowing:

— to sell goods or render services with the distribution,

Kingdom;

Section 9: No person shall be allowed to advertise goods
using the name or brand of tobacco products as a brand

of such goods in such a manner as to make such a brand
understood to be that of tobacco products;

Section 10: No person shall be allowed to manufacture,
import for sale or general distribution, or advertise any

goods having such an appearance as to be understood to
be an imitation of such tobacco products as cigarettes or

cigars, under the law on tobacco, or of the packaging of
said products;

Section 17: Any person violating Section 4 or Section 5
shall be subject to an imprisonment not exceeding one
month or a fine not exceeding 2000 Baht or both;

Section 18: Any person violating Section 6, Section 7,
Section 9 or Section 10 shall be subject to a fine not
exceeding 20000 Baht;

Section 19: Any person violating Section 8 paragraph one
shall be subject to a fine not exceeding 200000 Baht;

addition or gift of tobacco products, or in exchange for
tobacco products, as the case may be;

— to sell tobacco products with the distribution, addition,
gift of, or in exchange for, other goods or services;

— to give or offer the right to attend games, shows,
services or any other benefit as a consideration to

4

the buyer of tobacco products or a person bringing

Section 24: In case the violation of Section 4, Section 5,
Section 6, Section 8 paragraph one, Section 9, Section 10

or Section 13 is by manufacturer or importer, the violator

shall be subject to the penalty twice that provided for such
offences.

Thailand Country Report on Tobacco Advertising and Promotion Bans

The Tobacco Products Control Act 1992 contains a very

Direct advertising, for example:

comprehensive ban on advertising and promotion. It can

— installing large outdoor billboards advertising the ciga­

be summarized as follows:
The ban covers all media (Sections 3 and 8).
— The ban is almost complete, and includes sponsor­

ship. Although there is no such term as "sponsorship"

the definition of "advertising" (Section 3) means that
showing, mentioning, or referring to cigarette logos or
products is illegal. Therefore sponsorship, which must
show cigarette logos or product names is considered

an illegal act (Section 8).
— The only exceptions are live radio or television broad­
casts from abroad, and advertisements in printed

media published outside Thailand (Section 8).

— The ban covers all indirect advertising:
• point-of-sale (POS) advertising is not allowed.

Although the law does not specify POS, it is covered
by the phrase, "or anywhere else which may be

used for advertising purposes", in Section 8;
• product placement (Sections 3 and 8);
• trademark diversification (TMD) (Section 9);
• advertising goods that have an appearance such that

they are understood to be in imitation of tobacco

products or of the packaging of said products

rette brands Winston, Kent and Salem; billboards were
also placed in the international airport and its tax-free
shops;
— painting the logo “Mild Seven" on the bodies of ciga­

rette delivery vans;
— launching new cigarette brands, such as Waves of

Japan Tobacco Inc., with giveaways, exchanges, etc.

POS advertising, for example:
— placing numerous empty cartons in front of shops;
— placing large dispensers displaying logos, at sales

points;
— suspending mobiles (imitating cigarette packaging) in

such places.
Product placement, for example:
— wearing a t-shirt exhibiting the "Lucky Strike" logo in
a television drama;

— publishing pictures with cigarette logos in magazines

and calendars, advertising other products in newspa­

pers, yearbooks etc.;
— printing cigarette brand names on clothes and post­

cards.

(Section 10); and
• sponsorship (Sections 3 and 8).

The ban covers several promotional activities:

— prohibition of sale to minors (Section 4);
— prohibition of sale through vending machines (Section

5); and

TMD, for example:
— advertising a "Marlboro Country Tour" on television;
— setting up a billboard with the logo "Winston - Style

of the USA" across a street;
— advertising in newspapers "Kent Leisure Holidays",

“555 The Statesman Collection" and "Camel Boots”.

— prohibition of exchanges, free premiums, redemption,
giveaways, etc. (Sections 6 and 7).

Steps of Implementation

Sport sponsorship, for example:
— football: telecast of the "555 Football Special";
— snooker: telecast of the "555 Asian Snooker Open"

10

February 1989-3 August 1992:

Prohibition under the Consumers Protection

Act 1979

Because the CPB was not knowledgeable about tobacco
industry tactics, the secretary of the NCCTU monitored
violations and notified the CPB, which then prosecuted
cases accordingly. Violations included the following:

and the "555 World Series Challenge";

— golf: a small billboard with the logo "Salem" at the
venue of the "Singha Beer Pro-Am Tournament";

— cricket: a small billboard at the venue of the "Benson
& Hedges Cricket International";

— motorcycling: a "Lucky Strike-Suzuki" team competed
in a race.

All of these violations were discovered by the NCCTU
secretary and were sent to the CPB for prosecution. Some

5

World Health Organization

cases were investigated and fines resulted, and in some
cases the final result was not known. The fines were up to
40000 Baht, according to the stipulations of the Consumer

— cigarettes advertised in Thai Airways' duty-free price
list. In the May-June 1994 issue there were full-page
advertisements for Marlboro, Dunhill and 555. There

Protection Act. The billboards were ordered to be removed

were several cigarette advertisements in the Thai

by the CPB.

Airways in-flight magazine "Swasdee". In the January

After promulgation of the CPB advertising ban, violations

of the law by the transnational tobacco companies (TTCs)
continued the wrongdoing that had existed previously.

Violations and circumventions that occurred long after the
enactment of the advertising ban were either through the
TTCs pretending to be naive, or because they wanted to

test the effectiveness of law enforcement.

1994 issue, on one page there were advertisements

for Marlboro, Mild Seven, Dunhill and 555; there was
advertising for the "555 Subaru World Rally Team” in

the June and August 1994 issues.
POS. In retail outlets selling foreign cigarettes
there were:

— colour pictures of cowboys, the camel logo, and the
logo "get lucky” installed on cigarette cabinets;

4 August 1992-present: Prohibition under
the Tobacco Products Control Act 1992

— large signs showing prices and price reductions for cer­
tain brands.

The Minister of Public Health appointed officials of the
MOPH, the Ministry of Interior, Municipalities, the Excise

Product placement included:

Department, and the Customs Department, to be respon­

— wearing clothes with cigarette logos on television

sible for the enforcement of this law. Approximately
3000-4000 officials were appointed on 25 August 1992
and on 9 June 1993. There was only one meeting, held

shortly after the TPCA enactment, for the appointed offi­

cials to clarify the law. The supposed law enforcers are
from various government agencies with wide-ranging

shows;

— smoking by principal characters, especially the heroes
and heroines, in television shows:

— displaying tobacco brand names in calendars, e.g. a
Honda car calendar depicting several Marlboro logos;

responsibilities. Their superiors are not interested in tobac­

— advertisements for other products in newspapers, e.g.

co control. Most of the appointed MOPH officials have

an advertisement for Shell Oil included a picture of a

several identity cards for enforcing several laws and never

Formula One car displaying both Shell and Marlboro

utilize them. This is a major flaw of the Thai bureaucratic
system of law enforcement.

logos;

— pictures in magazines and on the sports pages of

Appointed officials from the Institute of Tobacco

newspapers showing cigarette logos on cars, athlete's

Consumption Control (ITCC) of the Department of

clothes, etc.

Medical Services (DMS) are supposed to form the core of
law enforcement in this area. There has been no official

TMD included:

report of violations recorded by the ITCC. The president

— advertising "Winston House” and "Camel Trophy

of the Thailand Health Promotion Institute (THPI) is at the
same time the drafter of the laws, the establisher of the
Office of Tobacco Consumption Control (later the ITCC),
and the former boss of the ITCC director. He used this

informal relationship to push the ITCC director to take

Adventure Wear" in newspapers;

— advertising "Camel Trophy Adventure Wear” and
"Marlboro Classics" on posters installed in shopping
outlets and in other media on different occasions.

action in several cases of violation of the law, but very
few results were achieved. The THPI is a nongovernmental

Sport sponsorship included:

organization and the THPI president is a retired govern­

— participation by the "555 Subaru" team in the Asia-

ment official. Both have no authority in law enforcement.

Pacific Rally, 3-6 December 1993;

— publicity for a visit by Mild Seven-sponsored Formula
The THPI has been the only organization that has com­
piled lists of practices violating the law. They included:
6

— Direct advertising, for example:

One driver Michael Schumacher, dressed in his racing
suit. This was followed by the "95 Formula-1 Festival"

at a department store on 14-30 October 1994;

Thailand Country Report on Tobacco Advertising and Promotion Bans

— THPI research found that in one year (1998-1999) a

Success of the Intervention

cable television station aired 1343 hours of tobacco-

sponsored sports events, consisting of 99 live legal tel­
ecasts and 1698 repeats. According to the law only live

During the first period (10 February 1989-3 August

1992) when the advertising ban was under the Consumer

telecasts are permitted (see Section 8 of TPCA 1992).

Protection Act 1979, the intervention was reasonably suc­

Therefore the repeats are considered illegal.

cessful. Almost all cases notified to the CPB by the NCCTU

Secretary were investigated and led to fines.
Other promotions, for example:

— in December 1992, the tax-free shops at the Bangkok
International Airport ran a promotional programme:

people buying goods worth 1000 Baht would be enti­
tled to a reduction of 100 Baht for other goods, includ­
ing cigarettes.

After 4 August 1992, the MOPH became responsible for
the newly enacted Tobacco Products Control Act 1992
and law enforcement has become very weak. The THPI

has been the main monitoring force and provided numer­

ous notifications to the ITCC. Most of these were not
dealt with efficiently. In a few cases, however, suppression
of the tobacco industry's promotional activities was suc­

cessful owing to the THPI’s vigilance and strong media
advocacy.

Success Story 1
Defeat of the Olympic Committee of Thailand's attempt to adopt tobacco sponsorship

In October 1990, the secretary of the Olympic Committee of Thailand (OCT) gave a press interview stating that the
OCT would consider accepting TTC sponsorship of sport, and that the OCT would push for amendment of the law

banning cigarette advertising.

On 21 October, the secretary of NCCTU gave a press interview opposing the proposal. This was followed by streams
of news items, columns, and articles supporting and opposing the planned sponsorship. From October 1990 to March

1991, there were 20 news stories and 24 articles in favour of sponsorship; 18 news stories and 15 articles opposed it;

and there were 9 news stories, 7 articles and 1 cartoon expressing a neutral stance. The pro-sponsorship group includ­

ed the Secretary and Treasurer of the OCT, a former Deputy Public Health Minister, and a large number of sport col­
umnists. The opposition consisted of the Secretary of the NCCTU, the Secretary of the No-Smoking Campaign Project,
the Public Health Minister, the Privy Councillor, and some journalists.
After the continuous 5-month debate, the pro-sponsorship group gave up.

World Health Organization

Success Story 2
Thailand was the only country in which the “Subaru-555" logo could not be displayed in the

Asia-Pacific Rally

1993 was the first year of the Asia-Pacific Rally, which was held in six countries: Australia, Hong Kong (now Hong
Kong Special Administrative Region of China)-Beijing (China), Indonesia, Malaysia, New Zealand and Thailand. After

the race, the THPI and its grass-roots allies gave a press conference stating that exhibiting the "Subaru-555" logo was
illegal. The MOPH followed up with a letter of protest to the organizers of the rally. The planned domestic rallies - four

in 1993 - were scrapped.
From 1994 on, the "Subaru 555" logo was changed to "Subaru III" when the rallies were held in Thailand.

Success Story 3
Thailand is the only country on the Asian golf circuit in which Davidoff logos are not
displayed

The Asian Professional Golf Association (Asian PGA) had the watch company, Omega, as its main regional sponsor
until 1999, when Davidoff took over. The Asian PGA's "Davidoff Tour” tournaments were held 20 times in 11 coun­
tries.

In Thailand there were 2 tournaments - The Lexus International on 14-17 October 1999, and The Thailand Open on
1-4 December. Both times, local organizers were told by the THPI president that displaying Davidoff logos was illegal.

The Lexus tournament did not heed the warning and the THPI president initiated an arrest by the ITCC staff. The tour­
nament organizer was prosecuted.

Since then, all Davidoff Asian PGA tours held in Thailand have not dared to exhibit the Davidoff logo. Thailand is the

only country on the tour to have "Davidoff-free" competitions.

8

Thailand Country Report on Tobacco Advertising and Promotion Bans

Success Story 4
British American Tobacco's (BAT) first nicophilantrophy was thwarted - a rare occurrence in
BAT’S history

Bangkok was once known as the "Venice of the East" because of the many canals that crisscrossed the metropolis.
One of the canals - Saen Saeb - was dug 166 years ago by royal order of the third king of the present Chakri Dynasty,
and in former times was a center for marine commerce. People used the 72-kilometre canal to travel to many districts

situated along its course, which went all the way to Chacoengsao Province in the east of the country. The pleasant

way of life has changed. Now the canal is filled with the sounds of insects and mosquitoes buzzing around. Travel

along the canal is no longer leisurely; boats emphasize speed to get through the polluted waters as quickly as possible.

Two daily newspapers of the Nation Multimedia conglomerate - The Thai language "Krungthep Turakit” and the

English-language "The Nation" - published half-page black and white advertisements for the project called "Clean
Saen Saeb Canal”, on 4, 8, 9, 14, 19, 21, 26, September and 3 October 2001. The main sponsor was British American
Tobacco (BAT) (Thailand) Inc. The captions read as follows: “Returning Life to Saen Saeb Canal is Returning Life to

the People", "Saen Saeb: Venice of the East Once More", etc. Publicity was also carried out through a television

channel and a radio station owned by the Nation Group. Billboards were installed along the banks of the canal. On 22
September a colourful festival was organized and the Governor of Bangkok ceremoniously received a donation from

BAT’s country manager. This was the first act of nicophilantropy by the company since its recent establishment as
BAT's subsidiary in Thailand.

An NGO, funded by the Thai Health Promotion Foundation, compiled a list of the types of misconduct carried out by
BAT from its own internal documents, and published a booklet, Facts about BAT. This was sent to the chairman of the

Nation Group along with a letter requesting him to abandon BAT’s sponsorship.

From 3 October on, publicity for the project ended. The NGO's grass-roots allies wrote to the Nation chairman thank­
ing him for his conscientious decision.

There have been failures as well, including the following:

_

is a law prohibiting such activity. The law controls

Philip Morris has been sponsoring an Association of

radio and television broadcasting and the responsible

South East Asian Nations (ASEAN) Arts Award since

agency is the public relations department of the Prime

1994. In the first year of the award, the THPi president

used press interviews to oppose the activity, supported
by the MOPH, the No-Smoking Campaign Project,
the Medical Council, and some newspaper columnists.

In spite of this activity, Philip Morris has continued to

Minister's office.
— TMD in the form of "Camel Trophy" stickers are past­

ed onto cars roaming all over the country.

— Cigarette logos can be seen in numerous tobaccosponsored sport telecasts on cable television.

hold the yearly contest until today. Sponsorship shows
only the Philip Morris company logo. Since the ciga­

Conclusion

rette brand name is not displayed, the act cannot be
considered as illegal.
— POS promotional activities at tens of thousands of
retail shops all over the country, which are illegal, have

not been dealt with.
— Product placement on television is still rampant, even
increasing, especially in foreign films televised by cable
companies across the country - even though there

Thailand has a very good and strong law with an excep­
tionally comprehensive ban on advertising, promotion and

sponsorship. However, law enforcement has been very

weak and circumventions and violations are still common.
To prevent an increase in people's tobacco consumption,

enforcement of the advertising ban must be comprehen­

sively planned and efficiently implemented.

Tools for Advancing Tobacco Control

in XXIst century:

Success stories and lessons learned

Outils pour poursuivre la lutte antitabac
au XXPsiecle:

Experiences concluantes
et nouveaux enseignements

Taxation (including
Smuggling
Control)

Report on Tobacco Taxation
in the United Kingdom

WHO/NMH/TFI/FTC/03,10

PH'

Tobacco Free Initiative would like to thank

the Centers for Disease Control and Prevention (CDC), Atlanta, USA

for their generous support for this project.

© World Health Organization 2003
All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination,
World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476: fax: +41 22 791 4857:

email: bookorders@who.int). Requests for permission to reproduce or translate WHO publications - whether for sale or

for noncommercial distribution - should be addressed to Publications, at the above address (fax: +41 22 791 4806;
email: permissions@who.int).

The designations employed and the presentation of the material in this publication do not imply the expression of any
opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory,
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0

Report on Tobacco Taxation
in the United Kingdom
Excise Social Policy Group
HM Customs and Excise

World Health Organization

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

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Report on Tobacco Taxation in the United Kingdom

Introduction1
Taxation levels

The United Kingdom has among the highest levels of

tobacco tax in the world1. Table 1 shows the current duty

rates for tobacco products while Table 2 presents taxation
levels. The latter is based on a typical pack of each product

and on the most popular price category for cigarettes.

Table 1
Current United Kingdom tobacco duty rates

Product

Duty rate

Cigarettes

22% ad valorem and £94.24 (130.24 Euro) per 1 000

Cigars

£137.26 (189.69 Euro) per kilogram

Hand-rolling tobacco

£98.66 (136.35 Euro) per kilogram

Other tobacco (e.g. pipe tobacco)

£60.34 (83.39 Euro) per kilogram

Source: HM Customs and Excise (HMCE)
Note: VAT at 17.5% is also charged on the total cost of tobacco products, that is, their value plus the duty charged on them.

Table 2
Comparison of selling price and tobacco tax

Product

Typical selling price

Total tax (Excise duty

Total tax as a %

and value added tax)

of selling price

Cigarettes (pack of 20)

£4.51

£3.55

78.7%

Small cigars (pack of 5)

£3.05

£1.37

45.0%

Hand-rolling tobacco (25g)

£4.60

£3.15

68.5%

Pipe tobacco (25g)

£3.55

£2.04

57.5%

Source: HM Customs and Excise

Tobacco Journal International Yearbook, Fact Sheet

Number 18, 2002.

3

World Health Organization

Figure 1
Smoking prevalence (percentage of adult population who smoke cigarettes and hand-rolling tobacco in the United Kingdom)

Source: Office of National Statistics, General Household Survey, 2000-2001

Smoking prevalence
Smoking prevalence (the proportion of the adult popu­

lation over 16 who admits to smoking) in the United
Kingdom declined steadily throughout the 1970s and

1980s. Since then the rate of decline has slowed but it
remains on an overall slight downward trend*2.

Treating smoking-related illnesses costs the National Health
Service in excess of £1.5 thousand million a year.

Taxation and tobacco policy
Brief historical facts about tobacco taxes

The United Kingdom has a very long history of taxing
Product trends

The majority of smokers in the United Kingdom smoke

tobacco. Excise duty on tobacco was first introduced in

1660. The present structure of specific and ad valorem

cigarettes3. Since 1997 there has been a trend for smok­

ing cheaper brand cigarettes4 and also for increased use
of hand-rolling tobacco5. Although the percentage of the

population who smoke has been decreasing since 19961997, the percentage smoking hand-rolling tobacco has

been increasing slightly since then.6
Prevalence of cigar smoking has declined substantially

2 Office of National Statistics, General Household Survey
2000-2001

3 Office of National Statistics, General Household Survey
2000-2001

4 HM Customs and Excise

since 19747. Although cigars are smoked mostly by men,

use by women is increasing slightly due to their consump­

tion of miniature cigars.8 Prevalence of pipe tobacco smok­

ing is now very low. Nearly all pipe smokers are men.9

Health
Smoking is the greatest single cause of premature death
and avoidable mortality in the United Kingdom, killing

some 120 000 people in the United Kingdom every year.

It is responsible for one death out of every five and causes

84% of deaths from lung cancer as well as 83% of deaths

4

from chronic obstructive lung disease, including bronchitis.

5 Office of National Statistics, General Household Survey
2000-2001

6 Office of National Statistics, General Household Survey
2000-2001

7 Office of National Statistics - General Household Survey
2000-2001

8 Gallaher Group, Gallaher Tobacco Category Review, 2002
9 Office of National Statistics - General Household Survey
2000-2001.

Report on Tobacco Taxation in the United Kingdom

Table 3
United Kingdom tobacco duty rates 1992 to date'

Cigarettes

Cigars

Hand-rolling

Other tobacco

tobacco

Date of

Ad valorem

Specific

Change

%

£ per 1000

10.03.92

21

44.32

67.89

71.63

29.98

16.03.93

20

48.75

72.30

76.29

31.93

30.11.93

20

52.33

77.58

81.86

34.26

29.11.94

20

55.58

82.56

85.94

36.30

01.01.95

20

57.64

85.61

85.94

37.64

28.11.95

20

62.52

91.52

85.94

40.24

26.11.96

21

65.97

98.02

87.74

43.10

01.12.97

21

72.06

105.86

87.74

46.55

01.12.98

22

77.09

114.79

87.74

50.47

£ per kg

£ per kg

£ per kg

09.03.99

22

82.59

122.06

87.74

53.66

21.03.00

22

90.43

132.33

95.12

58.17

07.03.01

22

92.25

134.69

96.81

59.21

17.04.02

22

94.24

137.26

98.66

60.34

' nominal terms
Source: HM Customs and Excise

excise duty on cigarettes was introduced in 1976 to

has been a vital element in the strategy of successive United

ease tax harmonization within the European Economic

Kingdom Governments to reduce smoking. Cigarettes,

Community (EEC).

which form the majority of the tobacco market in the United

United Kingdom tobacco duty rates

shows the current duty rates for tobacco products.

Kingdom, are now sold at historically high prices. Table 3

Since evidence shows that price increases have a major effect

on reducing both smoking prevalence and consumption,10
raising the price of tobacco products through duty increases

Tax rises from 1992
From November 1993 to November 1999 there was a
commitment to increase tobacco duties in real terms annu­
ally, initially by at least 3% on average and from July 1997

,0 Research includes: Curbing the Epidemic: Governments

by at least 5% on average.

and the Economics of Tobacco Control. Washington, D.C.,

tobacco; and Jha P, de Beyer J and Heller PS. Death and

In November 1999 the commitment to real increases was
replaced by Budget-by-Budget decisions on the level of

Taxes, Economics of Tobacco Control. Washington, D.C.

tobacco duty, although the Government made it clear

International Monetary Fund, December 1999.

that there was still a strong ongoing health case for real

The World Bank, 1999. At web site: www.worldbank.org/

increases.

5

World Health Organization

In 2000 tobacco duty was raised by 5% in real terms and
in 2001 and 2002 it was increased in line with inflation to

maintain the high price of cigarettes in real terms. Table 3
shows the tax rates on all tobacco products from March

1992 to date and Table 4 shows the percentage increase
in both real and nominal terms in tobacco duty over that
period. Figure 2 shows the duty (in nominal terms) on the

various tobacco products from March 1992 to the latest

increase in April 2002. It is based on a typical pack of each
product, i.e. 20 premium-price category cigarettes (the

Health initiatives
In 1998 the Government of the United Kingdom published

a White Paper Smoking Kills, which sets out a compre­
hensive strategy designed to reduce smoking. It includes

measures specifically targeted at those in lower income
groups. The initiatives include:
— a comprehensive ban on advertising, which begins to

come into effect in early 2003;
— a £76 million smoking cessation initiative from 1999-

most popular price category), 5 small cigars and a 25-gram

2000 to 2002-2003, including a targeted programme

pack of hand-rolling tobacco or other tobacco.

to address smoking during pregnancy, with a further

Use of tobacco taxes
Tobacco taxation brings in over £9 thousand million a

£138 million made available for 2003-2004 to 20052006;
— a large-scale health education campaign designed to

year in duty and VAT.” This is an essential source of

persuade smokers to quit and non-smokers not to

government funding for investment in public services

start; and

such as schools and hospitals. Furthermore, in 1999 the

Government of the United Kingdom announced that any
additional revenue raised from future real increases in

tobacco duty would be spent on improved health care.
Proceeds from the 5% real terms increase in 2000 con­
tributed to additional funding for the United Kingdom

VAT on tobacco products is estimated from the Office for
National Statistics figures for household consumption of

tobacco.

National Health Service (NHS).
Figure 2
Duty on tobacco products (in real terms at November 2002 prices) since March 1992

-=■=- Cigarettes
—_— Hand-rolling tobacco

6

C'sar5
Other tobacco, e.g. pipe tobacco

..
_.
Source: HM Customs and Excise
Cigar duty increases in the above figure
aPpear to
less than for the other tobacco products.
.. cau, by a reduction in the weight of a typical pack
of agars from 8.55 grams to 6.7 grams during this period.

Th.

Report on Tobacco Taxation in the United Kingdom

Table 4
Percentage increase* in tobacco duty per product from 1992" to date

Product

Nominal % increase

Real % increase

Cigarettes

113.1%

84.2%

Cigars

102.2%

73.3%

Hand-rolling tobacco

37.7%

8.8%

Other tobacco (e.g. pipe tobacco)

101.5%

72.6%

* Based on duty on a pack of 20 premium priced cigarettes and duty per kilogram for the other products

" From 11/3/92 Budget

Source: HMCE
Note, Duty on hand-rolling tobacco was frozen on several occasions due to concerns

about the effect of smuggling on its small domestic market.

— making smoking cessation aids available on NHS pre­
scription: Zyban (Bupropion) since 2000 and Nicotine
Replacement Therapy since 2001.

The Government of the United Kingdom12 believes that

maintain the real level of taxation on tobacco" and in 1992
increased tobacco taxes by 5% above the inflation rate.

In March 1993 tobacco taxes were again raised by more

than inflation. In the autumn of 1993 a joint pre-Budget

the United Kingdom now has one of the most compre­

submission by several health organizations called for unique

hensive smoking cessation services in the world.

treatment for tobacco because of its health consequences.

In November 2002 details of a further accelerated drive

This included a request for a real increase in the forthcom­

to combat smoking were announced. This includes an

ing Budget and a commitment to real increases in future.

increase in hard-hitting public awareness campaigns and

The Health Minister asked the Finance Minister to establish

new health warnings of significantly increased size on the

"future real increases". The 'tobacco escalator' was intro­

front and back of cigarette packs. A partnership is being

duced, which promised rises in tobacco duty of at least 3% in

developed between the Government and the pharmaceuti­

real terms in future Budgets. The reasons given for this were:

cal industry to assess how they can work better together

— to raise revenue;

to reduce smoking. The Government of the United

— to encourage further reductions in the levels of smok­

Kingdom's Department of Health is seeking to develop a

rebate system whereby pharmaceutical companies com­
pensate the National Health Service (NHS) part of the

additional money they receive from seeing cessation grow
and prescriptions rise.

ing; and
— to demonstrate the Government's commitment to the
Saving Lives: Our Healthier Nation White Paper.

In 1994 tax on cigarettes was raised by 4.2% above infla­

tion while tax on hand-rolling tobacco was raised by 3%

Policy implementation________________

above inflation. A second increase in tax was announced

in December 1994 that added an extra 3.7% tax to ciga­
Sequence of tax changes

rettes from January 1995.

In 1992 targets to reduce adult smoking by 40% by 2000
were published.13 These targets, related to consumption

12 Department of Health

of cigarettes, were set against a background of steadily

13 Saving Lives: Our Healthier Nation White Paper.

decreasing prevalence, a trend that stalled in the mid-

Presented to Parliament by the Secretary of State for

1990s when there was an increase in tobacco smuggling.

Health, the Stationery Office, July 1999.

The Conservative Government committed to "at least

0

World Health Organization

By 1995 tobacco smuggling had begun to take root, in

particular hand-rolling tobacco smuggling. Tax on ciga­
rettes was raised by 4.6% above inflation, but tax on
hand-rolling tobacco was frozen because of concerns about
the impact of smuggling on its small domestic market.

Lobby for and against policy
As already mention in paragraph 3.2, several health organi­
zations submitted a joint paper in 1993 calling for unique

treatment of tobacco because of its health consequences.
They considered that the general affordability of tobacco

Although cigarette smuggling was being contained in

products had been unaffected by the previous tax rises and

1996, there was concern that it was switching from ama­

they noted that the market was changing with the intro­

teur gangs to organized crime. Customs were allocated

duction of cheaper cigarette brands. They also considered

additional staff to deal with smuggling. Tax on cigarettes

that the introduction of tax stamps and law enforcement

was raised by 5% above inflation while tax on hand-roll­

were the appropriate way to tackle smuggling and that it

ing tobacco was raised in line with inflation.

should not be addressed by a reduction in duty rates.

In 1997 the new Labour Government announced an

Health and anti-smoking groups have been supportive of

increase in the ‘tobacco escalator' from 3% to 5%

tobacco policy, including Tackling Tobacco Smuggling,

because of its concern about the rates of death and

since that time. Prior to the 2002 Budget these groups

disease attributable to active and passive smoking. The

said they believed that "greater emphasis should now be

increased escalator was one of the measures intended to

placed on raising prices through addressing the trends

reduce tobacco consumption and dissuade young people

that tend to drive prices down rather than on increasing

from taking up the habit. Tax on cigarettes was increased
by 5% above inflation while tax on hand-rolling tobacco
was frozen again because of the impact of smuggling on

headline tax rates for cigarettes." The trends include the

supply of cheap, unregulated tobacco through the smug­
gling market.

its small domestic market.

Tobacco manufacturers, retailers and tobacco workers

In 1998 and 1999 tax increases were the same as in 1997.
Tobacco smuggling continued to grow, and in 1999 the
Government commissioned an independent review by

a senior businessman of tobacco smuggling. In 2000
the Government, acting on recommendations made in

this review, announced their strategy Tackling Tobacco
Smuggling to address the growing tobacco smuggling
problem. This included a new Government investment of

£209 million over three years to reduce smuggling. The
strategy provided additional customs staff and a network

of x-ray scanners, funded a major publicity campaign,
introduced fiscal marking of cigarettes and hand-rolling
tobacco along with related new criminal offences, and

introduced a tough vehicle seizure policy.

In November 1999, the Government announced that

it was abandoning the ‘tobacco escalator' in favour of
Budget-by-Budget decisions. It also said that future real

increases in tobacco taxes would be spent on improved
health care. Taxes were increased by 5% above inflation in

2000 and with inflation in 2001 and 2002 to maintain the
real cost of cigarettes. At the same time the Government

sought to increase the average price of cigarettes for

the consumer by clamping down on the supply of cheap
smuggled products through the successful Tackling
Tobacco Smuggling strategy.
8

groups have continually blamed the tobacco smuggling

situation on the level of tobacco taxation in the United
Kingdom and have called for significant reductions in duty

to tackle smuggling. However over the last year manufac­
turers have publicly acknowledged an increase in legiti­
mate trade due to the success of the Tackling Tobacco

Smuggling strategy. Despite this, both manufacturers
and retail trade groups lobby at every opportunity for a

decrease in tax levels to reduce the differential between
the tax level in the United Kingdom and in other nearby
European Union (EU) countries.

Effect of the taxation policy
Tobacco prices
Cigarette prices in the United Kingdom are now at histori­

cally high levels. Although high tax levels are the major
factor in these high prices, manufacturers' pre-tax prices
are also significantly higher in the United Kingdom than

elsewhere in the world for the same product. For example,
in 2001 the pre-tax price of 20 Benson & Hedges Special

Filter cigarettes was 93p in the United Kingdom, 48p in
France and 39p in Greece.14

Report on Tobacco Taxation in the United Kingdom

Table 5
Prevalence of cigarette smoking by sex and socioeconomic group

Socioeconomic group

Men

Professional

15%

13%

Employers & managers

22%

21%

Intermediate & junior non-manual

26%

25%

Skilled manual & own account non-professional

34%

27%

Semi-skilled manual and personal service

36%

34%

Unskilled manual

39%

34%

Total non-manual

23%

22%

Women

Total manual

35%

30%

All aged 16 and over

29%

25%

Source: Office of National Statistics, General Household Survey 2000-2001

Smoking prevalence

Impact of tobacco taxation policy

Smoking prevalence (the proportion of the adult popula­

Revenue

tion who admit to smoking) has been declining but at a

slow rate recently. In 1992 it was 29% and in 2000 it was

From 1992 to approximately 1997 revenue from tobacco

27%.15 Figure 1 shows the decline in a longer time scale.

taxes was increasing. There followed a period of decreas­
ing revenue until early 2000 due to the revenue loss

Although taxation plays an important role in reducing

caused by tobacco smuggling. Since then tobacco duty

smoking, it is not possible to isolate the effect of taxation.

revenue has started to increase again because of the suc­

Smoking is affected by an entire range of measures such

cess of the United Kingdom Tackling Tobacco Smuggling

as health campaigns and targeted cessation programmes.

strategy. The latest estimate of tobacco revenue being

It is also affected by social trends, e.g. the acceptability of

smoking or peer pressure for young people.
Social groups

evaded or avoided is £4.3 thousand million for 2001-

2002. However, this includes about £1 thousand million

from legitimate cross-border shopping (duty-free and EU
duty-paid goods). Table 6 shows tobacco duty revenue

Table 5 illustrates that smoking prevalence increases down
the socioeconomic groups. Manual workers are also likely

to consume more cigarettes than those in non-manual

15

have smokers and smoking is increasingly linked with

Office of National Statistics - General Household Survey
2000-2001

professions. Households with children are more likely to
16

Even if tobacco duties are regressive this does not mean

poverty. Tobacco duties are regressive: lower-income

that increases in tobacco duties are. A paper by Townsend

households are more affected by duty increases than richer

et al., Cigarette smoking by socioeconomic group, sex,

ones 16 This is why the Government balances high tobacco

and age: effects of price, income, and health publicity,

taxes with real support for people to quit (see "Health

British Medical Journal 1994, 309:923-927, shows that

initiatives").

when the price of cigarettes increases, lower-income
groups decrease their consumption more than do higherincome groups.

9

World Health Organization

from 1992-1993 to 2001-2002, although the latter is a

Tobacco manufacturers

provisional figure.
We cannot provide detailed information on the United
Kingdom tobacco manufacturers' profits, but Imperial

Table 6
United Kingdom tobacco duty revenue in fmillion

Tobacco, the United Kingdom's largest manufacturer,

recently announced a 27% increase in operating profit.
(in real terms at November 2002 prices)

Year

Revenue fmillion

Despite the high levels of tobacco taxation and smuggling,

tobacco manufacturers continue to make large profits. As
already mentioned in paragraph 4.1, pre-tax prices in the

1992-1993

7,551.3

1993-1994

8,007.2

1994-1995

8,837.6

1995-1996

8,448.0

a more orderly market.

1996-1997

9,093.7

Tobacco smuggling

1997-1998

9,152.4

The introduction of the single market in 1993 and ease of

1998-1999

8,712.4

1999-2000

5,939.0

2000-2001

7,764.5

2001-2002*

7,754.5

United Kingdom are much higher than in other countries.

During 2002-2003 manufacturers publicly acknowledged
the success of the Tackling Tobacco Smuggling strategy,

which has increased legitimate sales and begun to restore

travel to neighbouring EU countries where tobacco prod­
ucts were priced lower that those in the United Kingdom
both led to increased tobacco cross-border shopping and
smuggling as United Kingdom prices rose. Initially the
smuggling was confined to cross-Channel smuggling of

hand-rolling tobacco but it soon increased to both cross­
Channel and freight smuggling of cigarettes.

* Provisional
Source: HM Customs and Excise

By 1999 the revenue lost through tobacco smuggling was
an estimated £2.5 thousand million, which was about
25% of all tobacco revenue; smuggling was on a strong

upward trend. Customs estimated in 2000 that without

Figure 3
Percent market share of smuggled cigarettes

Report on Tobacco Taxation in the United Kingdom

intervention the smuggled share of the cigarette market

fair to honest shoppers, tough on criminal smugglers and

would have reached over a third by 2002-2003. Figure 3

clear about the distinction between the two. This pack­

shows the trend in cigarette smuggling and the projected

age includes an increase in the guidelines, which are an

trend with and without the Tackling Tobacco Smuggling

indicator that a traveller has brought a significant quantity

strategy.

of tobacco goods into the United Kingdom, to about six

In March 2000 the Government announced its strategy
to tackle the tobacco smuggling problem, investing £209
million over three years toward this end. The Tackling

months' use for an average smoker.

Conclusion

Tobacco Smuggling strategy provided additional resources

Smoking is the single greatest cause of preventable illness

and technology (x-ray scanners) for customs, funded a

and premature death in the United Kingdom, killing over

publicity campaign and led to the introduction of fiscal

120 000 people a year. Research shows that the demand

marks on tobacco and hand-rolling tobacco in 2001, with

for cigarettes is affected by price18 so high tax levels have

new criminal offences related to their use. The strategy

played a significant role in reducing overall consumption.

set challenging targets for customs to slow, stabilize and

In particular, high tobacco prices are a valuable deterrent

reverse the growth in tobacco smuggling by the end of

to children who are tempted to take up smoking. Various

2002-2003.

other benefits occur for individuals, society and the econo­

Customs achieved its first year target and held the illicit

my through a reduction in smoking:

share of the cigarette market to 21 % in 2000-2001. In

— non-smokers enjoy healthier and longer lives than

2001-2002 customs continued to restrict the illicit share

smokers and smokers who quit can eventually achieve

to 21 % (when its key target was 22%) thereby stopping

almost the same levels of health as those who have

the growth in tobacco smuggling for the first time in a
decade.*17

In the first two years of the Tackling Tobacco Smuggling
strategy customs:
— broke up 103 gangs involved in large-scale cigarette

smuggling; and

_

seized in excess of 5 thousand million illicit cigarettes.

never smoked;
— there is an economic benefit particularly for low-

income families for whom money spent on tobacco
can be a large proportion of income;

— the risk of fire is reduced;
— industry benefits from reducing lost time due to smok­

ing breaks at work and the higher absence rates of

smokers19; and

In 2001-2002 the network of x-ray scanners detected 13
tonnes of hand-rolling tobacco and 325 million cigarettes.

— there are savings to the NHS.20

Revenue lost from tobacco smuggling is now estimated to

be some £3.3 thousand million, a slight decrease from the
previous year.

17 The methodology for calculating the illicit market share

was published in Measuring Indirect Tax Fraud as part

The strategy has also had a significant impact on cross­

of the Pre-Budget Report, November 2001 (avail­

Channel smuggling of hand-rolling tobacco. The estimated

able on the United Kingdom Government web site:

revenue lost from this is now £95 million compared to
approximately £785 million two years ago.

www.hmce.gov.uk)

18 Research includes Curbing the Epidemic: Governments

and the Economics of Tobacco Control, The World

Cross-Channel shopping

The introduction of the single market in 1993 led to an

increase in cross-border shopping as well as smuggling.

As a result of the success of the Tackling Tobacco
Smuggling strategy, cross-Channel smugglers have increas­
ingly sought to pose as honest shoppers in an attempt to

evade customs controls. In October 2002 the Government
announced a new package of measures designed to be

Bank, 1999 and Jha P, de Beyer J and Heller PS. Death

and Taxes, Economics of Tobacco Control, International
Monetary Fund, 1999.
19 See for example: Parrot et al. Costs of employee smoking

in the workplace in Scotland. Tobacco Control, 2000, 9
pp. 187-192.

20 Department of Health

Over the last ten years tax on tobacco products in the

United Kingdom has risen significantly, mostly well in

excess of inflation.
Unfortunately, the effect of these increases has been

undermined by tobacco smuggling, which increases the

availability of cheap smuggled products. Not only does this
make cigarettes more affordable, it also decreases revenue
required for investment in public services such as health

and education.

The Government of the United Kingdom believes that the
way to tackle tobacco smuggling is through enforcement

and it will not allow criminal activity to dictate its policies
to improve the nation's health. Health and anti-smok­
ing groups have supported that approach. The successful

Tackling Tobacco Smuggling strategy is currently address­
ing this problem and restricting the illicit share of the total

cigarette market.

Tobacco manufacturers frequently call for the United
Kingdom duty rates to be reduced to rates that are closer
to those of the neighbouring EU countries. However at

the same time those same manufacturers contribute to

the current historically high cigarette prices in the United
Kingdom by setting their pre-tax prices in the country at

levels significantly above those for the same product in

other countries, including those belonging to the EU.

The United Kingdom believes that focusing on differen­
tials between the United Kingdom and EU countries is

misleading and misses the key issue, which is that the vast
majority of illicit goods have borne no tax in any country.

Cutting duty levels to those prevalent in countries from
which smuggling occurs would cost thousands of millions

of pounds in revenue. The shortfall in revenue would
either mean less investment in essential public services or

increases in other forms of taxation to fund them. Lower
cigarette prices would increase consumption, lead to more

premature deaths and smoking-related illnesses and incur

further costs for the National Health Service.

The United Kingdom has therefore tackled tobacco use by
a multi-pronged approach. It has used a package of health

measures along with taxation to bring about a reduction
in smoking. Where this has been undermined by tobacco

smuggling, the United Kingdom is tackling this criminal

activity and has sought to increase the effective price of
cigarettes by reducing the supply of cheap smuggled prod­
ucts and so raising the share of the market taken by more
expensive legitimate products.

12

Tools for Advancing Tobacco Control

in XXIst century:

Success stories and lessons learned

Outils pour poursuivre la lutte antitabac

au XXIsiecle:

Experiences concluantes
et nouveaux enseignements

I

Taxation (including
Smuggling
Control)

Earmarked Tobacco Taxes
and the Role of the Western Australian Health
Promotion Foundation (Healthway)

WHO/NMH/TFI/FTC/03.11

Tobacco Free Initiative would like to thank

the Centers for Disease Control and Prevention (CDC), Atlanta, USA

for their generous support for this project.

© World Health Organization 2003

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0
Best Practices in Tobacco Control
Earmarked Tobacco Taxes and the Role

of the Western Australian Health
Promotion Foundation (Healthway)
Suzanne Cordova
Injury Research Center

School of Public Health
University of Western Australia

World Health Organization

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

WHO Regional Office for Africa (AFRO)

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Telephone: +202 670 2535

2

(WPRO)

Best Practices in Tobacco Control Earmarked Tobacco Taxes and the Role of the Western Australian Health Promotion Foundation (Healthway)

Introduction

those described above. Compared with a similar survey

undertaken in 1996, the largest reduction in smoking
The concept of creating health promotion foundations,

prevalence occurred in females aged 16 to 17 years, with

funded by a portion of the tobacco excise revenue

the proportion smoking in the preceding week falling from

was developed in Australia. These foundations provide

29% to 20%% (3).

sponsorship to sports, arts and racing organizations
and replace tobacco industry sponsorship and outdoor

Disease and death toll of tobacco

advertising. The Victorian Health Promotion Foundation

Between 1985 and 1996, about 19% of all deaths in WA

VicHealth, founded in 1987, was the first of its kind. This

were due to addictive substances and, of these, 79% were

report will describe the implementation and evaluation

due to tobacco smoking with an average of 1 502 deaths

of the Western Australian Health Promotion Foundation

each year (4). Nationally, there were approximately

Healthway, which was established under the Western

19 000 deaths and about 140 000 episodes of hospitaliza­

Australian Tobacco Control Act of 1990. With a popula­

tion attributable to tobacco smoking in 1998. The annual

tion of 1.9 million, Western Australia (WA) has about one-

cost of these hospitalizations was about SAUD 390 million.

tenth of the total Australian population, and is the largest

The most frequently occurring tobacco-related conditions

Australian state in geographical terms.

were cancers, ischaemic heart disease and chronic airflow

Current situation and recent trends in

tobacco use
The 2001 National Drug Strategy Household Survey of
almost 27 000 Australians aged 14 years and above found
that the proportion of respondents who smoked daily

declined by just over 2% between 1998 and 2001, from
21.8% to 19.5%. Overall, the prevalence of smoking has
been falling since 1945 among males and since 1976 in

females, although the downward trend has slowed some­
what in recent years. Based on the survey, it is estimated

that in 2001 approximately 3.6 million Australians aged
14 years and over were smokers and just under 3.1 million

smoked daily (1).

While the state-specific figures for the 2001 survey
were not yet available at the time of writing, some West

Australian figures from the 1998 survey are notable.
Among 20 to 29 year-olds, WA had the lowest regu­

lar smoking rate in Australia, with 29.1 % of this group
reporting daily or near-daily smoking (Australian average:
31.6%). WA also had the lowest regular smoking rate

among 14 to 19 year-olds, at just 9.9% (Australian aver­

age 16.1 %). Among regular West Australian smokers, the
typical quantity of cigarettes consumed in 1998 was 11 to

limitation (5).
During the 1998-1999 financial year, the Commonwealth

Government received over SAUD 8 thousand million in

revenue from the importation and sale of tobacco products
in Australia. However, data from customs and excise sug­

gest a slight fall in the demand for tobacco products over

the five years up to 1999-2000 and there was a decrease
in per capita consumption of cigarettes in Australia from

8th in the world in 1991 to 17th in 1996 (5).

Description of the policy intervention
WA Tobacco Control Act 1990
The WA Tobacco Control Act 1990 was passed in

December 1990 and came into effect in February 1991.

The purposes of the Act were to actively discourage
tobacco smoking and to promote good health and prevent
illness by encouraging non-smokers, particularly young

people, not to start smoking; by limiting the exposure of
children and young people to persuasive messages about
smoking; and by encouraging and assisting current smok­

ers to quit.

Healthway

20 cigarettes per day (2).
The Act outlined the creation of the Western Australian

In 1999, a survey on drug use was conducted among

Health Promotion Foundation (Healthway) and prohibited

3 458 12 to 17 year-old WA school students. The results

tobacco advertising, tobacco sponsorships, competitions

indicated that 21 % of students had smoked at least once

run by tobacco companies and distribution of free tobacco

in the last four weeks, 17% had smoked at least once in

samples, though the Minister of Health was permitted to

the last week and 4% had smoked daily. Overall, 52% of

grant exemptions under certain circumstances.

students had smoked at least a few puffs of a cigarette in
their lifetime. These figures appear to be consistent with

3

World Health Organization

The objectives of Healthway, as stated in the legislation,

Healthway funding: earmarked tobacco taxes

are:
— to fund activities related to the promotion of good
health, with particular emphasis on young people;

In the early years, Healthway received SAUD 12.9 million
each financial year for its activities. More recently, a 2.5%
funding increase per annum has been granted to keep in

— to offer an alternative source of funds for sporting and

line with inflation. Accordingly, Healthway's annual budget

arts activities currently supported by manufacturers or

stands at about SAUD 16 million. For this, Healthway must

wholesalers of tobacco products;

endeavour to ensure that, in each financial year, at least

— to support sporting and arts activities that encourage
healthy lifestyles and advance health promotion pro­

grammes;
— to provide funds to replace tobacco advertising with

health promotion advertising;
— to provide grants to organizations engaged in health
promotion programmes;

30% is disbursed to sporting organizations; at least 15% is

distributed to arts organizations; and not more than 50%
is earmarked for any single group, be it sports, arts, health,

community, youth, research or racing organizations.
Until 1997, Healthway was funded by earmarked tobacco

taxes, namely, a portion of the state tobacco franchise

fee. This fee was introduced under the WA Business

— to fund research relevant to health promotion;

Franchise (Tobacco) Act 1975 as a wholesale tax or licence

— to raise funds by soliciting donations and grants to

fee, which was paid in regular instalments by wholesale

support its work; and
— to evaluate and report on the effectiveness of its per­

formance in achieving health promotion activities.
Established on 8 February 1991, Healthway remains gov­

erned by a Board representing arts, sports, health, youth
and country interests. Originally reporting to the Board

were five advisory committees: arts, health, racing, sports
and tobacco replacement. Currently, there are six com­

mittees: sports, arts, racing, health, research and finance.

These committees, comprising members appointed for
their relevant expertise, have a direct role in reviewing

sponsorship and grant applications and in making funding
recommendations to the Board.

tobacco merchants. The rate was based on the wholesale
value of tobacco sales in the preceding period and rose
incrementally from 10% in 1976 to 100% in November
1993

(Table 1) (7).

In August 1997, Healthway's source of funding changed
when the High Court of Australia ruled that it was uncon­

stitutional for states to charge state-based tobacco taxes.
Since then, the Federal Government has collected state
tobacco franchise fees on behalf of the states, which it

then returns as part of the state's funding. As a result,
health promotion foundations in Australia are now funded

by direct allocation from consolidated revenue (8).
The establishment of Healthway in February 1991 was not

directly linked to an increase in the state tobacco franchise

Phasing out of tobacco sponsorship and

fee. A rise had occurred in January 1990, when the fee

outdoor advertising

was raised from 35% to 50%, and a further rise occurred

in November 1993, when the fee was raised from 50% to

By 8 February 1992, all tobacco sponsorship in WA had
been replaced, unless specifically exempted by the Minister

of Health. Outdoor tobacco advertisements were removed
gradually, with approximately 50% by July 1992, a further

25% by July 1993 and the remaining 25% by July 1994.
Health promotion messages replaced about 25% of the

total outdoor advertising space formerly held by tobacco

100% (7). This may have assisted the passage of the leg­
islation, as opposition from the tobacco companies would
likely have been greater had an attempt been made to

raise the state tobacco franchise fee in conjunction with
the ban on tobacco industry sponsorship and outdoor
advertising.

companies and non-tobacco advertisers used the remain­

In the 1992-1993 financial year, WA had the lowest state

der. For a period of five years following the passage of the

franchise fee (50%) in Australia and reports of an illegal

legislation, the Act required Healthway to give priority to

cross border trade from WA to higher taxed states devel­

organizations and individuals disadvantaged by the ban­

oped. The rise in the tobacco franchise fee to 100% in late

ning of tobacco sponsorship and advertising, by replacing

1993 resolved the issue and the average cost of a packet

tobacco activities with health sponsorship and advertising

of 30 cigarettes in WA rose by SAUD 1.76, from SAUD

(6).

4.23 to SAUD 5.99 (7).

Best Practices in Tobacco Control Earmarked Tobacco Taxes and the Role of the Western Australian Health Promotion Foundation (Healthway)

Table 1
The history of smoking control in Western Australia (WA)

Year

Smoking control activity

1911

WA statute prohibited smoking in cinemas and theatres

1917

Sale or supply of cigarettes to children under 18 years made illegal

1950

Association between smoking and lung cancer reported in British Medical Journal (11)

1967

Australian Council on Smoking and Health (ACOSH) established

1972

Health warnings on cigarette packets became mandatory Australia-wide

1976

Federal legislation banned direct cigarette advertising on radio and television

WA Tobacco Franchise Fee introduced (10%), January
1982

WA Smoking and Tobacco Products Advertisements Bill to ban tobacco advertising defeated
WA Tobacco Franchise Fee raised (12.5%), March

1983

WA Tobacco (Promotion and Sales) Bill, 2nd unsuccessful attempt to ban tobacco advertising
The Smoking and Health Programme of the WA Department of Health established

Federal Tobacco excise increased and linked to consumer price index (CPI), November

WA Tobacco Franchise Fee raised (35%), December

1984

First Quit Campaign in WA

1987

Federal legislation banned smoking on all domestic airline flights and instituted revised health warnings on
cigarette packets

1988
1990

In the Australian state of Victoria, the first health promotion foundation VicHealth, is established under state
legislation
Federal ban on cigarette advertising on radio and television extended to all tobacco products

WA Tobacco Franchise Fee raised (50%), January
WA Tobacco Control Act passed, December
1991

Federal ban on tobacco advertisements in the print media, December

1992

Western Australian Health Promotion Foundation Health way formally established 8 February

1993

All tobacco sponsorship in WA ended 8 February, unless specifically exempted by Health Minister
Healthway's programme of replacing outdoor tobacco advertising commenced

Federal Government legislates to ban tobacco sponsorship Australia-wide
1994

Federal tobacco excise increased above CPI
WA Tobacco Franchise Fee raised (100%), November

1995

Federal tobacco excise increased above CPI
Phasing out of all outdoor tobacco advertisements in WA completed, July
WA "Smarter than Smoking" youth campaign launched, partly funded by Healthway

Federal customs duty on imported tobacco and excise duty on domestic product harmonized

1999

Federal tobacco excise increased above CPI

2000

Tobacco sponsorship banned in Australia from 31 December

WA Health (Smoking in Public Places) Regulations banned smoking in enclosed public places, including res­
taurants. (Exemptions: bars and some gaming areas)
"Per stick" rather than weight-based tobacco excise system introduced by Federal Government increases
cigarette prices
Further price rise after Goods and Services Tax introduced in July

World Health Organization

Table 2
Key stakeholders for and against a ban on tobacco sponsorship and advertising

Pro-legislation

Asthma Foundation of Western Australia
Australian Council on Smoking and Health
Australian Medical Association (Western Australian branch)

Cancer Foundation of Western Australia
Department of Health, Western Australia

Health Education Council of Western Australia
National Heart Foundation (Western Australian division)

Public Health Association of Australia
Royal Australasian College of General Practitioners (Western Australian faculty)

Royal Australasian College of Pathologists (Western Australian committee)
Royal Australasian College of Physicians
Royal Australasian College of Surgeons

Thoracic Society of Australia (Western Australian branch)
Tuberculosis and Chest Association of Western Australia
Anti-legislation

Advertising Federation of Australia
Australian Association of National Advertisers
Australian Cinema Advertising Council

Australian Publishers Bureau
Australian Retail Tobacconist
Confederation of Australian Motor Sport

(WA branch)

Ethnic Press Association of Australia

Federated Tobacco Workers' Union of Australia

Newspaper Advertising Bureau of Australia
Outdoor Advertising Association of Australia
Tobacco Institute of Australia
Tobacco companies
WA Cricket Association & Indoor Cricket Super League
WA Dart Council
WA Football League, Rugby League & Rugby Union
WA Golf Association

WA Greyhound Racing Association
WA Motion Pictures Exhibitors' Association
WA Sporting Car Club

WA Trotting Association
Source: Musk AW, Shean R, Woodward S. Legislation for smoking control in Western Australia. British Medical Journal, 1985, 290:1562-1565.
Castleden VM, Nourish DJ, Woodward S. Changes in tobacco advertising in Western Australian newspapers in response
to proposed government legislation. Medical Journal Australia, 1985,142:305-308

Best Practices in Tobacco Control Earmarked Tobacco Taxes and the Role of the Western Australian Health Promotion Foundation (Healthway)

Steps of implementation

tion foundation, funded by the WA tobacco franchise fee,
which would buy out tobacco sponsorship and replace

The passage of the WA Tobacco Control Act 1990 was

outdoor advertising of tobacco products. With concerns

not without difficulty. Two previous attempts to ban

about revenue loss by potential opponents of the leg­

tobacco sponsorship and advertising in WA in 1982 and

islation allayed and with the successful passage of an

1983 had failed. The history of tobacco control in WA is

Australia-wide ban on tobacco advertising in newspapers

one of setbacks and gains. Table 1 outlines progress to

and magazines, the WA Tobacco Control Act 1990 was

date.
Following the Federal Government's ban on cigarette

advertising on television and radio in 1976, the tobacco
industry sought to exploit an exemption of the legisla­

passed, banning tobacco industry sponsorship and outdoor

advertising in WA.

The intervention's success

tion, which allowed cigarette advertising in the electronic

media if it occurred incidentally or accidentally. As a result,

Healthway programmes and priority areas

sponsorship of televised sporting events carrying arena

Healthway runs a number of programmes: a Health

advertising for tobacco products increased. The volume of

Promotion Projects Programme, a Health Promotion

advertising matter in the print media also rose (9).
WA Smoking and Tobacco Products

Advertisements Bill, 1982

Research Programme, a Sponsorship Programme and a

Tobacco Replacement Programme (6). In addition to its
sponsorship and advertising activities, Healthway offers

annual grants for health promotion projects and research.

In 1982, in an attempt to ban tobacco industry sponsor­

A number of research priority areas have been identi­

ship and outdoor advertising, the Smoking and Tobacco

fied, with the prevention and control of tobacco smoking

Products Advertisements Bill was introduced into the West

receiving the highest funding allocation (Table 3).

Australian parliament. The bill was defeated following a
massive lobbying campaign by the Tobacco Institute of

Australia, the Australian Publishers Bureau, by organiza­

Table 3

tions with a well-defined interest in continued tobacco

Healthway's programme and research priority areas

promotion and by sports organizations sponsored by

Alcohol and other drug misuse

tobacco companies. Full-page advertisements and newspa­

per editorials claimed that the legislation was an infringe­

Asthma prevention and control

ment of civil liberties and would have a detrimental effect

Cardiovascular disease prevention, including

on sport and employment (9).

hypertension control

WA Tobacco (Promotion and Sales) Bill,

Cancer prevention, in particular, skin cancer prevention

1983

A second attempt to introduce a ban was undertaken
in 1983, with the WA Tobacco (Promotion and Sales)
Bill. Again, the volume of tobacco industry advertising
increased markedly (70) and the bill was defeated, despite

the state government's campaign to "Give kids a chance".
That year, the WA tobacco franchise fee was raised from

12.5% to 35% and $AUD 2 million was appropriated for

smoking education (9). Table 2 lists a number of the key
stakeholders for and against the ban on tobacco industry

sponsorship and outdoor advertising at that time.

Determinants of healthy behaviour
Diabetes prevention
Good nutrition
Healthy environments

Indigenous health
Injury prevention

Mental health promotion

Physical activity promotion

WA Tobacco Control Act, 1990

Sexual health (includes HIV/STI prevention)

A third attempt was made in 1990. On this occasion, the

Tobacco smoking prevention and control

ban was linked to the establishment of a health promo­

World Health Organization

Health promotion in recreational settings

The introduction of smoke-free policy was an incremental

process. Initially, as part of the sponsorship agreement,

Healthway’s health promotion objectives are based on the
principles of the Ottawa Charter. In particular, Healthway
seeks to create supportive environments and healthy pub­

Healthway requested the creation of smoke-free areas.
Later, as contracts were renegotiated, Healthway required
venues and events to become entirely smoke-free (8).

lic policy, strengthen community action and work collabo­
ratively across sectors. Before the establishment of health

Prior to the implementation of smoke-free policies, a

promotion foundations, recreational settings had a minor

survey was conducted at major sporting venues to assess

role in health promotion. Yet since Healthway's inception,

public support for this activity and the majority favoured at

research has indicated that the average West Australian

least some restrictions (13). After introduction, the support

attends a foundation-sponsored event on four occasions

among spectators actually increased further, particularly

per year and that Healthway is particularly effective in

among non-smokers (14). Furthermore, Pikora et al. (15).

reaching the most disadvantaged 10% of young people.

found that the level of compliance with the policy at two

Many participants also have elevated risk factor profiles

major sporting venues in WA was high, indicating that

compared with the general population (12). Thus, rec­

the measure was effective in protecting non-smokers from

reational settings present an opportunity to deliver health

environmental tobacco smoke. The successful introduction

messages to broad sections of the community, including

of smoke-free sports venues helps to create social norms

those traditionally considered hard to reach.

that strengthen support for smoke-free areas in public

places.
Health sponsorship in recreational settings

Health sponsorship dollars can be used to negotiate ben­
efits such as naming rights, signage, player endorsement

Healthway evaluation
The Health Promotion and Evaluation Unit of the School

of a health product and structural reforms such as smoke-

of Population Health at The University of Western

free areas and health catering (8). When Healthway pro­

Australia evaluates Healthway programmes. In the early

vides sponsorship funds for larger grants, it simultaneously

years, the University's Graduate School of Management

awards support funds to an independent health agency to

was also involved. Evaluation is necessary to ensure that

promote an audience-appropriate health message at the

Healthway is meeting its health objectives. For projects

event. For small grants, Healthway provides a health pro­

attracting funds valued at over SAUD 25,000, post-event

motion support kit (6).

surveys are undertaken to assess cognitive and attitudinal

Examples of agencies that have received Healthway

funds include the National Heart Foundation, Diabetes
Association, Cancer Foundation, Asthma Foundation,

Australian Sports Medicine Federation, Kidsafe, Australian

Council on Smoking and Health, and the Alcohol Advisory
Council. Healthway also provides support to smaller com­

munity-based organizations. This helps to achieve a more
equitable distribution of health-promoting resources within

the community (6).
Achieving structural reforms: Smoke-free

policies

measures such as awareness, comprehension and accept­

ance of the event's health message, using a standardized
questionnaire. Encouragingly, past surveys (n=5 710) have

indicated that 67% of respondents could recall the health

message; of those, 82% had understood it; of those,
88% had accepted it; and of those, 9% (or 4% of the
total number of respondents) intended to act on it (6).

Evaluation data from 2001 report a further improvement
with 9% of the total sample intending to act on the health

message (16).

Tobacco replacement
Tobacco replacement venues refer to those settings previ­

Structural reforms to create healthier environments have

been introduced into sports, art and racing venues by
Healthway. These reforms include smoke-free areas,

healthy catering, sun protection measures, safe alcohol
practices, safe exercise practices and improved access for

disadvantaged groups (6).
8

ously sponsored by the tobacco industry. Such venues

offer opportunities for structural reforms, promotion of
anti-smoking messages and targeting of at-risk groups.
On evaluation of Healthway’s tobacco replacement pro­

gramme, replacement projects achieved a level of direct
population reach for a given amount of funding that

was four times higher than other sponsorship projects.

Best Practices in Tobacco Control Earmarked Tobacco Taxes and the Role of the Western Australian Health Promotion Foundation (Healthway)

Table 4
Achievements of the 1990 legislation

Achievements of the WA Tobacco Control Act 1990
1)

The WA Health Promotion Foundation (Healthway) established

2)

Tobacco sponsorship prohibited and replaced with Healthway sponsorship

3)

Tobacco advertising restricted to point of sale only from July 1994

4)

Distribution of free tobacco samples and competitions involving tobacco products banned

5)

Penalties for the sale of tobacco to minors raised

6)

Facilitated the passage of a national ban on tobacco advertising, effective as of end of 1995

Achievements of the WA Health Promotion Foundation (Healthway)
1)

Promotion of health messages at sports, arts and racing venues

2)

Replacement sponsorship to organizations previously sponsored by tobacco industry by 8 February 1992

3)

Sponsorship for other sports and arts organizations

4)

Replacement of all outdoor tobacco advertising by 1 July 1994, 25% replaced directly by health promotion messages

5)

Implementation of structural changes at venues e.g. smoke-free areas, healthy catering

6)

Collaboration with sectors outside of health including recreational and cultural sectors

7)

New source of Government funding for health promotion research and community projects

8)

Facilitated the introduction of the WA Health (Smoking in Public Places) Regulations, which banned smoking in
enclosed places, including restaurants in 1999

Source: Holman CD, Donovan RJ, Corti B. Report of the evaluation of the Western Australian Health Promotion Foundation. Health

Promotion Development and Evaluation Programme, The University of Western Australia. 1994
Musk AW, et al. Progress on smoking control in Western Australia. British Medical Journal, 1994, 308:395-398.

Structural change towards a smoke-free environment was
also obtained more often. However, surveys have revealed
a higher resistance to health messages at these sites (17).

Effects of programme on smoking prevalence

Achievements
The achievements of the WA Tobacco Control Act 1990

and Healthway are summarized in table 4.

Other impacts of the intervention

The overall trend in the prevalence of smoking in WA
has been downward. While there are numerous reasons

Effect on government finances and tobacco

behind reductions, which cannot be attributed to any

company revenue

single tobacco control measure, it is likely that the ban on

tobacco sponsorship and outdoor advertising and the work
of Healthway have contributed to the fall in prevalence.

The establishment of Healthway was not directly linked to
an increase in the state franchise fee. However, by 1995,

almost two-thirds of the retail price of a packet of ciga­

In 1998, the prevalence of smoking among young West

rettes in WA was accounted for by the federal excise duty

Australians was the lowest in the country. This may in part

and state franchise fee (7). With respect to the tobacco

be due to the Smarter Than Smoking campaign, which

companies, during the early 1990s, increased taxation,

began in 1995, with the aim of discouraging smoking

limitations on advertising opportunities, negative publicity

among young people. This initiative receives funding from

about tobacco products and an economic recession affect­

Healthway.

ed industry profitability. Locally, the WA Tobacco Control

9

World Health Organization

Act 1990 contributed to this. Competitive price discount­

places, including restaurants, with a limited number of

ing ensued and by August 1994, these subsidies were

exemptions for bars and some gaming areas. WA was the

costing the tobacco companies some SAUD 8 million per

first state in Australia to implement such legislation.

week. The companies recognize that the Australian market
is declining and are turning to more profitable ventures in

Conclusion

the Asia-Pacific region (19).

The health promotion foundation model was developed

Banning tobacco-funded research

primarily to replace tobacco sponsorship and outdoor

Healthway has successfully banned tobacco-funded

advertising, using a portion of the revenue raised from

research at WA's four major universities by making it a

government tobacco taxes, with health-promoting alter­

condition of funding that organizations do not accept

natives including anti-smoking messages and structural

financial support from the tobacco industry. At the time,

reforms. Secondary benefits include the creation of new

these universities were among only 13 of the 45 universi­

opportunities for health sponsorship and the availability

ties across Australia reported to have even discussed the

of an additional funding source for health promotion pro­

issue (8).

grammes and research. Healthway, a model that has been

Paving the way for further anti-tobacco

one example of what a health promotion foundation can

legislation

achieve.

used in a number of Australian states and in California is

By creating smoke-free venues with community support,

It is this author's opinion that health promotion founda­

Healthway paved the way for further tobacco control

tions are an effective tobacco control measure and could

measures. In 1999, the WA Health (Smoking in Public

be used more widely, in both developed and developing

Places) Regulations banned smoking in enclosed public

countries. However, strong leadership, a stable govern-

Table 5
Achieving change: lessons for tobacco control advocates and policy-makers

1)

Identify realistic objectives and priorities

2)

Adopt an incremental approach to change

3)

Coordinate professional networks

4)

Develop a strategic plan

5)

Educate decision-makers

6)

Secure an ongoing funding arrangement, preferably using tobacco taxes

7)

Collaborate with a variety of sectors and organizations

8)

Foster cooperative relationships with sponsored organizations

9)

Recruit community support and involvement

10)

Select audience-appropriate health messages

11)

Develop opportunities for structural reforms

12)

Renegotiate contracts on a regular basis

13)

Evaluate programmes, including reach, impact and outcomes

14)

Communicate progress to stakeholders and the community

Source: Musk AW et al. Progress on smoking control in Western Australia. British Medical Journal 1994:308.395-398.

Corti B et al. Warning attending a sport, racing or arts venue may be beneficial for your health. Australian and New Zealand Journal of

10

Public Health 1997, 21:371-376

Best Practices in Tobacco Control Earmarked Tobacco Taxes and the Role of the Western Australian Health Promotion Foundation (Healthway)

merit and a commitment to health are required to achieve

Drug and Alcohol Office, 1995, at web site: http://

this type of change and some important lessons are listed in

www.wa.gov.au/drugwestaus/.

Table 5. Undoubtedly, there will be strong opposition from

the tobacco companies and extensive consultation with cur­

8.

341-51.

to allay fears of revenue loss as a result of the proposed
changes. Several iterations may be required before legislation

Giles-Corti B, et al. Creating smoke-free environments in

recreational settings. Health Education Behaviour, 2001, 28:

rent recipients of tobacco company largesse will be required
9.

Musk AW, Shean R, Woodward S. Legislation for smoking

is passed. On the other hand, since this measure is not reliant

control in Western Australia. British Medical Journal, 1985,

on an increase in tobacco taxes per se, it may be easier to

290:1562-1565.

introduce this strategy in between tobacco tax increases, as

occurred in Western Australia.

10.

Castleden VM, Nourish DJ, Woodward S. Changes in tobac­

co advertising in Western Australian newspapers in response

Finally, any comprehensive national or state-based tobacco

to proposed government legislation. Medical Journal

control programme relies on a number of strategies,

Australia, 1985,142:305-308.

including legislation, taxation, education, and environ­
mental and organizational change. Establishing a health­

11.

replace tobacco advertising and sponsorship is one inno­

Doll R, Hill AB. Smoking and carcinoma of the lung.

Preliminary report. British Medical Journal, 1950;ii:739-748.

promotion foundation using earmarked tobacco taxes to
12.

Oddy WH et al. Epidemiological measures of participation in

vative and effective component that can be added to the

community health promotion projects. International Journal

armamentarium.

of Epidemiology, 1995, 24:1013-21.

References
1.

. 2001 National Drug Strategy Household Survey: First

13.

14.

Results. Canberra, Australian Institute of Health and Welfare,

Fitzsimmons G & Cooper-Stanbury M 1998 National Drug

Jones S et al. Public response to a smoke-free policy at a

major sporting venue. Medical Journal Australia, 1996, 164:

Drug Statistics Series No. 9, AIHW cat. No. PHE 35, 2002.
2.

Corti B et al. Public attitudes to smoke-free areas in sports

venues. Medical Journal Australia, 1995:162:612.

759.
15.

Pikora T et al. Are smoke-free policies implemented and

Strategy Household Survey: State and Territory Results.

adhered to at sporting venues? Australian and New Zealand

Canberra, Australian Institute of Health and Welfare, Drug

Journal of Public Health, 1999, 23:407-409.

Statistics Series no. 5, cat. No. PHE 26, 2000.

16.

3.

Saunders J et al. Healthway's sponsorship programme: 10

Drug use among 12 to 17 year-old Western Australian

years of evaluation. Perth, Health Promotion Evaluation Unit,

school students in 1999: A summary report. Perth,

Department of Public Health. The University of Western

Population Health Division, Department of Health, Western

Australia, 2002.

Australia and the Centre for Behavioural Research in Cancer,

Anti-Cancer Council of Victoria, 2002.

17.

Holman CD et al. Banning tobacco sponsorship: replacing
tobacco with health messages and creating health-promoting

4.

Unwin E and Codde J. Trends and patterns of drug-caused

environments. Tobacco Control 1997, 6:115-21.

mortality in Australia and Western Australia. Australian and

New Zealand Journal of Public Health 1999, 23:352-356.

18.

Musk AW et al. Progress on smoking control in Western

Australia. British Medical Journal, 1994, 308:395-398.
5.

Miller M, Draper G. Statistics on drug use in Australia 2000.

Canberra, Australian Institute of Health and Welfare Drug

19.

Tobacco in Australia: Facts and Issues. Victorian Smoking and
Health Programme, Australia (Quit Victoria), 2nd Ed, 1995

Statistics Series no.8, AIHW cat. no. PHE 30, 2001.

ISBN 0 646 14103 1.

6.

Holman CD, Donovan RJ, Corti B. Report of the evaluation

of the Western Australian Health Promotion Foundation.
Health Promotion Development and Evaluation Programme,

The University of Western Australia, 1994.
7.

Western Australian Drug Strategy. Protecting the commu­
nity. Vol. 2, Ch 10, Task Force on Drug Abuse, Tobacco.

20.

Corti B et al. Warning attending a sport, racing or arts venue

may be beneficial for your health. Australian and New

Zealand Journal of Public Health 1997, 21:371-376

Tools for Advancing Tobacco Control

in XXIs* century:

Success stories and lessons learned

Outils pour poursuivre la lutte antitabac
au XXPsiecle:

Experiences concluantes
et nouveaux enseignements

Labelling and Packaging —
(including Health
p^ < i r.
Warnings)

Thailand Country Report
on Labelling and Packaging

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

WHO Regional Office for Africa (AFRO)

WHO Regional Office for Europe (EURO)

Cite du Djoue

8, Scherfigsvej

Boite postale 6

DK-2100 Copenhagen

Brazzaville

Denmark

Congo

Telephone: +(45) 39 17 17 17

Telephone: +(1-321) 95 39 100/+242 839100

WHO Regional Office for South-East Asia (SEARO)
WHO Regional Office for the Americas I Pan

American Health Organization (AMRO/PAHO)

525, 23rd Street, N.W.

World Health House, Indraprastha Estate
Mahatma Gandhi Road

New Delhi 110002

Washington, DC 20037

India

U.S.A.

Telephone: +(91) 11 337 0804 or 11 337 8805

Telephone: +1 (202) 974-3000

WHO Regional Office for the Western Pacific
WHO Regional Office for the Eastern

Mediterranean (EMRO)

WHO Post Office

(WPRO)
P.O. Box 2932
1000 Manila

Abdul Razzak Al Sanhouri Street, (opposite Children's

Philippines

Library)

Telephone: (00632) 528.80.01

Nasr City, Cairo 11371

Egypt
Telephone: +202 670 2535

Thailand: Country Report on Labelling and Packaging

Introduction
From 1981 to 2001 there were dramatic changes in tobac­

co consumption in Thailand. The total number of smokers
rose from 9.7 million in 1981 to 10.6 million two decades
later. Smoking prevalence declined from 35.2% to 22.5%

during the same period. The male smoking rate decreased
from 63.2% to 42.9%, while female prevalence fell from

0

Table 1
Estimated number of deaths from diseases in

South East Asia, 2001

Diseases

Deaths

Cancer of trachea, lung, and bronchus

35 000

Cancer of mouth and oropharynx

16 000

Respiratory diseases

130 000

Ischaemic heart diseases

232 000

5.4% to 2.4.%. Per capita consumption rose from about
774 in 1970 to 1 087 in 1980. Since that time, it has

decreased progressively to 798 in 2000.
Figure 1
Per capita consumption estimates 1970-2000

Source: World Health Report, 2002. Geneva, World Health
Organization, 2002.

In terms of cancer of the various organs, lung cancer was

the second most common cancer between 1988 and 1991
in Thailand. Women in the northern region of the coun­

try, who have the highest smoking prevalence among the

various regions, have lung cancer at an age-standardized
incidence rate of 37.4 per 100 000 (1).

Policy intervention
Policy intervention on labelling and packaging, including

health warnings, only involves manufactured cigarettes.
This applies equally to both domestic and imported ciga­

rettes. Other tobacco products, e.g. cigars and pipe tobac­
Source: Developed by THPI from: Guidon GE, Boisdair D. Past,
Current and Future Trends in Tobacco Use.
HNP Discussion Paper.
Economics of Tobacco Control, Paper N° 6, February 2003.

co, are not included because there are too many varieties
of packages and it is difficult to carry out regulatory proce­
dures. In addition, the consumption level of these products

is low and small gains in health are not worth the regula­
There have been no systematic studies of morbidity and

tory effort.

mortality of tobacco-related diseases. Table 1 shows that

In Thailand, policy is based on legislative action. Initially,

the estimated number of deaths from various diseases in

the Medical Association of Thailand pressed for regula­

South East Asia for 2001 (within the low child and low

tory action and such issues were later taken up by the

adult mortality stratum to which Thailand belongs).

Announcement of Labelling Committee of the Consumers

Protection Board (CPB) pursuant to the Consumers
Protection Act 1979. This announcement became effec­
tive on 20 September 1990. Finally, labelling was man­
dated by successive Ministerial Announcements pursuant

to the Tobacco Products Control Act (TPCA) 1992. After
this Act became effective on 3 August 1992, the CPB’s

Announcement of Labelling Committee was disbanded.

These efforts are outlined chronologically in table 2.

3

World Health Organization

Steps toward implementation
Before 1989 there was no established national policy to
control tobacco consumption. In late 1988, the Deputy

Director-General of the Department of Medical Services

(DMS), proposed and received approval from the thenMinister of Public Health (later a two-time Prime Minister

of Thailand) to establish an inter-agency policy commit­

and Prime Minister’s office; Deputy Permanent Secretary

for Health of the Bangkok Metropolitan Administration;

Director-Generals of Departments of Health, Medical

Services, Excise, Public Relations; President of the
Reporters Association of Thailand, Secretary-General
of the Medical Council, and five experts. The Deputy-

Director-General was the NCCTU's first secretary.

The Ministry of Public Health (MOPH) proposed the for­

tee for tobacco control called the National Committee for

mation of the NCCTU. The proposal received approval

Control of Tobacco Use (NCCTU).

from the Cabinet and the Committee was formally estab­

In the proposal the committee appointed the Public Health

lished on 14 March 1989. This interagency body is now

Minister as the chairman. The members comprised chair­

responsible for formulating the country's policy on tobacco

persons of the standing committee on health of both

control. To this end it has initiated several tobacco control

the Senate and the House of Representatives. They were

policies, one of which was a regulation mandating health

the following: permanent secretaries1 of the Ministries of

warnings.

Public Health, Education, Agriculture, Interior, Finance,

Table 2
Chronology of regulation on labelling and packaging

The first health warning

1967

A secretary-general of the Medical Association of Thailand under Royal Patronage, who was also a chest
physician with post-graduate training in the United States of America, requested that the Ministry of
Finance require the Thailand Tobacco Monopoly (TTM) to print a health warning on cigarette packages

they produced. (The Ministry supervises the TTM, which was the only cigarette manufacturer in the coun­

try at that time).
1974

After a long delay, the TTM began printing the small health warning 'Smoking may be harmful to health’
on the side of cigarette packages.

The second set of health warnings
25 April

At its first meeting the NCCTU secretary proposed that there had been only one small health warn­

1989

ing placed on cigarette packets and six new rotating health warnings should be mandated. The NCCTU
approved the new set, which comprised the following messages: ’smoking causes lung cancer and emphy­

sema’, ‘smoking causes ischaemic heart disease’, ’smoking harms babies in the womb’, ‘respect other peo­

ple's rights by not smoking in public places', 'giving up smoking reduces serious illness' and 'for the sake
of your children please give up smoking'.

11 July
1989

The cabinet endorsed the MOPH proposal mandating health warnings on cigarette packages and ordered
the CPB to take further action.

18 May

The CPB’s Labelling Committee mandated a seventh health warning on cigarette packages, namely,

1990

■smoking may be harmful to health’ (this warning had been in place since 1974), as well as the six warn­

ings approved by the cabinet. These had to be placed in the front of the package, the size of the letters

had to be at least 1 mm wide and at least 2 mm high. The warning had to be evenly distributed among
the produced packages. This announcement became effective on 20 September 1990.

The procedures for enacting a law or a regulation pursuant to a certain section of a law must follow these
consecutive steps:

Thailand: Country Report on Labelling and Packaging

— a law is passed by the National Assembly;
— the Prime Minister proposes the law to His Majesty the King of Thailand;
— the King signs on to the law and returns it to the Prime Minister, who counter signs; and
— a regulation or ministerial announcement is sent to the Government printing house to be published

in the Royal Gazette. The announcement is publicized by the person responsible for that law, and

includes a statement on how many days following its publication the law will become effective.

The third set of health warnings

3 August

The TPCA 1992 was enacted and became effective as of 3 August 1992. Section 12 of this Act stated that

1992

‘the manufacturer or importer of the tobacco products must place the labels on the packages of tobacco
products before they leave the manufacturing site or before importation into the Kingdom2 as the case

may be.

The criteria, procedures and conditions of displaying these labels and the statements therein shall be in
accordance with those published in the Government Gazette by the Minister.3
25

Following a meeting of the NCCTU, it was decided that a new set of health warnings would be mandated.

August

The Ministerial Announcement, pursuant to Section 12 of the TPCA 1992, was issued mandating ten

1992

rotating health warnings on cigarette packages. They were the following: 'smoking causes lung cancer’,
'smoking causes heart disease", 'smoking causes lung emphysema', 'smoking causes obstructive or haem­
orrhagic stroke', 'smoking kills', ‘smoking is addictive', 'smoking is harmful to people around you', ‘smok­

ing is harmful to babies in the womb", 'quitting smoking reduces the risk of serious illness' and ‘giving up

smoking leads to a healthy body'.
The warnings had to occupy no less than 25% of the front and back of the main surfaces of cigarette

packages or cartons. The lines bordering the warnings had to be white and letters black. The size of the
font 'Si Phya' had to be 16 points for packages that have 37 cm2 of the main surfaces, 21 points for 3785 cm2, 33 points for 85 cm2 and 36 points for the cartons.

24 Sept.

1992

The announcement was published in the Royal Gazette and the regulation became effective one year
later.

This set of warnings represented a significant strengthening of tobacco control laws compared to previous
ones. This was largely due to the fact that MOPH had just passed its own law (the TPCA 1992), which

was a means of putting its regulations into effect. In addition, the Ministry had just established the first
national governmental agency for tobacco control - the Office of Tobacco Consumption Control, which
acts as a full-time secretariat for the NCCTU. The first and second set of health warnings were initiated by

other mechanisms outside the full control of the MOPH, that is, by the Medical Association of Thailand
under Royal Patronage and by the NCCTU via the Consumers Protection Act, which fell under the respon­

sibility of the CPB of the Prime Minister's Office. The third version was achieved by the NCCTU secre­
tariat.
A permanent secretary is the highest ranking permanent
official of a ministry.

"Kingdom'' is the legal term for the Kingdom of Thailand

"Ministers" means the Minister of Public Health who is
responsible for this Act.

5

World Health Organization

The fourth set of health warnings

___ ______ _____________

15

The NCCTU decided to mandate a new version of health warnings. The new Ministerial Announcement

October

was issued replacing the former one, mandating ten health warnings on cigarette packages, smoking

1997

causes lung cancer’, 'smoking causes heart failure’, ’smoking causes emphysema', smoking causes brain
haemorrhages, smoking causes leads to other addictions, ’smoking causes impotence', ’smoking causes
premature aging’, ’smoking can kill you’, ’smoke harms people near you’, and ’smoke harms babies in the

womb’. The warnings had to follow the requirements described below:
— The warnings, including bordering lines, must occupy no less than one-third of the principal surfaces of

the cigarette packages or cartons.

— The border must be white and 2 millimetres thick.
— The background must be black and the letters white.

— The letter font must be ’Si Phya’ and the size must be 20 points for packages with an area of 37 cm2
front and back, 25 points for an area of 37-80 cm2, 38 points for 80+ cm2 areas and 75 points for
cigarette cartons.

4 Nov.

The announcement was published in the Royal Gazette and became effective one year later.

1997
The fifth set of health warnings - the pictograms

Feb.

The president of the Thailand Health Promotion Institute (THPI), who was a DMS adviser, suggested to

2000

the then-Director-General of the DMS that Thailand mandate pictorial health warnings. The Director-

23 March

The MOPH approved the DMS proposal and set up a committee to consider graphic health warnings on

2000

cigarette packages. The DMS Director-General was the chairman and THPI president was the vice-chair­

5 April

At the first meeting TTM representatives opposed the printing of graphic health warnings on cigarette

General agreed and ordered the DMS's Institute of Tobacco Consumption Control (ITCC) to proceed.

man.

2000

packages. The THPI president, who was the meeting chairman, asked the TTM to submit an official letter
explaining its reasoning. In its letter the TTM stated that they only had a printer that could produce threecolour pictures. For four-colour pictures a new machine would have to be imported, and in addition to

costing 12 million Baht, it would take two to three years to acquire.
The THPI president asked the ITCC to ignore the TTM’s complaint and proceed to acquire three-colour

pictures for the health warnings.
The protracted delay in implementation could have been due to either the ITCC’s bureaucracy or the

tobacco industry’s underground lobbying. In Thailand the transnational tobacco companies never act
publicly because every time they do they are heavily challenged by the country’s strong tobacco control
advocates.
28 Feb.

During the NCCTU meeting the THPI president complained that the process of acquiring pictorial health

2002

warnings was dragging and the NCCTU ordered further action without delay. New subcommittees were

established, one for implementation of the TPCA.

26 April

2002

At the subcommittee meeting chaired by the THPI president it was decided that 12 pictorial health warn­

ings would be put in the Ministerial Announcement. The themes of the 12 pictures included the 10 previ­

ous warnings and 2 new ones ’smoking causes oral cancer’ and ’smoking causes foul odours and black­
ened teeth’.

Thailand: Country Report on Labelling and Packaging

3 May

After several contacts with the ITCC to determine the progress of preparing pictures and ministerial

2002

announcements, the THPI president found that there were certain obstacles in the process, namely, the

major difficulties in acquiring pictures through bureaucratic means. The THPI then decided to use media

advocacy to push for the policy's achievement by releasing a press message reporting that Philip Morris

had sent a letter dated 27 February to the Public Health Minister threatening to take legal action if the
MOPH ordered the printing of pictorial health warnings on cigarette packages.

4 May

The press release culminated in a continuous stream of news, letters, and articles in the media and in inter­

-17 June

national news agencies as well as numerous radio and television interviews, including CNN.

2002

11 May
2002

An entire week after news broke out of the Philip Morris threat the Public Health Minister stated in a press
interview that the MOPH did not believe that the decision mandating pictorial health warnings was con­

tradictory to the Constitution and TRIPS (Trade-related aspects of intellectual property rights), and that the
MOPH would go ahead with the plan.

17-21

The THPI president asked for and received a green light from the DMS to produce the pictures. It was

June

decided that five pictures, which depicted diseased organs, would be acquired from hospital slide librar­

2002

ies, that is, lung cancer, heart disease, emphysema, stroke, and oral cancer, and the other seven pic­

tures would be acquired by conducting a country-wide contest so that the public could participate. The

Photography Association of Thailand under Royal Patronage was invited to collaborate and the Thai

Health Promotion Foundation was asked to fund the contest.
3 July

Nongovernmental organizations (NGOs) organized the award ceremony for the contest winners. The

2002

Minister of Public Health was invited to chair the events.

6 Sept.

The THPI sent the complete set of pictorial health warnings to the DMS Director-General to draw up the

2002

ministerial announcement and proposal for the Minister of Public Health to sign.

1 Oct.

The newly organized MOPH proposed that tobacco control work be a part of the new Department of

2002

Disease Control (DDC).

1 Nov.

The THPI president sent a letter to the DDC Director-General urging him to expedite the long-delayed

2002

process.

20 Jan.

The DDC Director-General called a meeting to consider pictorial health warnings. THPI president and

2003

Action on Smoking and Health (ASH) Secretary-General were invited. The Director-General asserted that

the 12 pictures acquired did not seem to communicate very well to the viewers. The meeting decided to
have a pre-test for these pictures.
After acquiring satisfactory pictures there are still a few steps to be taken: drawing up the Ministerial

Announcement, sending a proposal to the MOPH Minister for signature; and publication in the Royal
Gazette. This regulation would become effective six months following its publication. The long interval

would provide ample time for the cigarette producers to clear their stock and produce the new labelling.

World Health Organization

Opponents counter the intervention

The tobacco industry does not want graphic health warn­
ings and would go to any lengths to obstruct this effort.

There are two main reasons:

this right unnecessarily because existing health warn­

ings already cover one-third of the pack."
— Reality: The Government also has the right to clearly

inform the people about the health hazards of smoking.

— The pictograms were found to be very effective. An

— Myth 4: "Trademarks are valuable Company property

evaluation in Canada showed that 44% of smokers

and are protected by the Trademark Act B.E. (Buddhist

said the pictorial health warnings increased their moti­

Era) 2534, the Penal Code, as well as by TRIPS, of

vation to quit, 58% thought more about the health

which Thailand is a member. TRIPS provides that the

effects of cigarettes, 27% were motivated to smoke

use of a trademark shall not be unjustifiably encum­

less inside their home, and 62% thought the picto­

bered by special arrangements, such as use in a special

grams make the packages look less attractive.

form or manner detrimental to its capacity to distin­

— Thailand would be the third country in the world to

mandate graphic health warnings if the regulation
passes and it would be an exemplary regulation that

other countries would follow.

guish the goods or service of one undertaking from

those of other undertakings. The Regulation would
violate this principle."
— Reality: The Trademark Act B.E.2534 prohibits destruc­

tion or imitation of trademarks. The pictograms would

The Philip Morris letter of 27 February 2002 was sent

do neither.

to the Public Health Minister, though no one knew her
response or that of her secretariat. The THPI president

TRIPS provides public health exception in Article 8.2,

knew of the Philip Morris action from a DMS official and

which states that the "Member may, in formulation or

asked a DMS Deputy-Director-General to fax the Philip

amending their national laws and regulations, adopt meas­

Morris letter. The THPI then used the letter for advocacy

ures necessary to protect public health and nutrition, and

in the media to reinforce the policy of educating smokers

to promote the public interest in the sectors of socioeco­

through pictorial health warnings.

nomic and technological development, provided that such

measures are consistent with the provisions of this agree­
The Philip Morris letter propagated four myths.

ment." Therefore, the regulation on pictograms does not

— Myth 1: "It would impose an undue burden on the

violate TRIPS.

Company in that Ministerial Regulation (No.6). B.E.
2543 already requisitions 33.3% of the total area of a

cigarette pack for the prescribed textual health warn­
ings.”

— Reality: What type and how big is the 'undue bur­
den?

The Philip Morris letter sent to the Public Health Minister
was meant only to bluff those who were unfamiliar with

Thailand's copyright law, its constitution and TRIPS. By
citing the risks involved in their taking legal action, the

tobacco multinationals had hoped that the MOPH bureau­
crats would stop the implementation process.

— Myth 2: "The Regulation would impair the use of
the Company's valuable trademarks by obscuring the

The intervention's success

marks on the pack face, thereby undermining the
trademarks' functions of brand identification and com­

Regulation on packaging and labelling has been quite

munication with the Company's customers. Packaging

successful. To date, the first four different sets of health

is more important for cigarettes than other prod­

warnings have been mandated. The number of rotating

ucts since all forms of advertising are banned by the

warnings has increased from one to twelve. The warn­

Tobacco Products Control Act.”

ing area size on cigarette packages and cartons has been

— Reality: The trademarks are still there and not
obscured.

enlarged from small letters on the sides of cigarette pack­
ages to one-third of the principal surfaces of packages,
including cartons. The last set of pictorial health warnings,

— Myth 3: "The Company has the right to communicate

with its customers through its display of trademarks
and logos. Any attempt to limit this right must be

necessary to achieve a legitimate public purpose. The

8

imposition of the graphic health warnings would limit

occupying half of the front and back, is being prepared
and it is hoped that it will be enacted in 2003.

Thailand: Country Report on Labelling and Packaging

In Thailand, there has been no scientific study of the
impact of cigarette package textual health warnings on

tobacco use.

Other impacts of the intervention
The graphic health warnings have created immense public

interest. There is widespread support from the media and
all sectors of society.
Media advocacy about pictorial health warnings has been

enormous as the following figures demonstrate:
— After the THPI press release, from 4 May to 17 June
2002, the subject was mentioned 16 times in the

newspapers and 6 of those articles were published on
front pages; 4 letters and 5 newspaper articles devoted
to the subject; at least 4 news releases by international

news agencies, including CNN, and innumerable radio

and television interviews.
— Before and after the picture contest described in Table 2,

from 17 June to 4 July 2002, pictorial health warnings
were mentioned 23 times in newspapers; there were 4
newspaper articles on the subject, 1 public opinion poll,

and numerous radio and television interviews.

Conclusion
Package labelling is a vital measure in controlling tobacco.

It should be mandated with minimum cost, changed

at appropriate intervals, and improved consistently.

Thailand’s legal system enables it to be easily implemented
because packaging and labelling is a section of the law

and regulation can be passed pursuant to the legislation.

Textual health warnings can be changed and upgraded
into pictorial ones that have, according to the Canadian

experience, better impact upon smokers.

References
1 Vatanasapt V et al. Cancer Incidence in Thailand 1988-1991.

Cancer Epidemiological Biomarkers & Prevention 1995; 4(3):
127-138.

9

Labelling and Packaging —™”
(including Health
Warnings)
'

Labelling and Packaging in Brazil

Tobacco Free Initiative would like to thank

the Centers for Disease Control and Prevention (CDC), Atlanta, USA

for their generous support for this project.

© World Health Organization 2003

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ommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors
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The World Health Organization does not warrant that the information contained in this publication is complete
and correct and shall not be liable for any damages incurred as a result of its use.

The named authors alone are responsible for the views expressed in this publication.

Printed in World Health Organization, Geneva.

0

Labelling and Packaging in Brazil
Tania Maria Cavalcante
National Cancer Institute

Health Ministry of Brazil

World Health Organization

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

WHO Regional Office for Africa (AFRO)
Cite du Djoue

Boite postale 6

WHO Regional Office for Europe (EURO)
8, Scherfigsvej

DK-2100 Copenhagen

Brazzaville

Denmark

Congo

Telephone: +(45) 39 17 17 17

Telephone: +(1-321) 95 39 100/+242 839100
WHO Regional Office for South-East Asia (SEARO)
WHO Regional Office for the Americas / Pan

American Health Organization (AMRO/PAHO)
525, 23rd Street, N.W.

World Health House, Indraprastha Estate

Mahatma Gandhi Road
New Delhi 110002

Washington, DC 20037

India

U.S.A.

Telephone: +(91) 11 337 0804 or 11 337 8805

Telephone: +1 (202) 974-3000
WHO Regional Office for the Western Pacific
WHO Regional Office for the Eastern

Mediterranean (EMRO)

WHO Post Office

(WPRO)
P.O. Box 2932

1000 Manila

Abdul Razzak Al Sanhouri Street, (opposite Children's

Philippines

Library)

Telephone: (00632) 528.80.01

Nasr City, Cairo 11371

Egypt
Telephone: +202 670 2535

Labelling and Packaging in Brazil

Introduction

exporter of non-manufactured tobacco (Ministerio da Saude,

Brazil is the largest country in South America, with an area

The National Tobacco Control Programs

2000; ILO, 2003).

of 8 547 403.5 square kilometres and a population of

169 799 170 (IBGE, 2000). Its geopolitical structure com­

The National Cancer Institute of Brazil (INCA) is the

prises 26 states and one Federal District, the capital of

Ministry of Health body that coordinates the National

Brazil, Brasilia. Each state is divided into municipalities, of

Cancer Control Policy and the National Tobacco Control

which there are a total of 5 507.

Programme.

The primary causes of death in Brazil are cardiovascular

INCA has coordinated the National Tobacco Control

diseases and cancer and their major risk factor is tobacco

Programme for the last 14 years. This programme encom­

use. Lung cancer is the leading cause of death by can­

passes four main strategy groups: prevention of smoking

cer among men and the second cause among women.

initiation, protection of the population from environmen­

In 1999, there were 14 127 deaths due to lung cancer.

tal tobacco smoke exposure, promotion and support for

Among women the mortality rate of lung cancer is increas­
ing faster than among men. An analysis of a temporal
series of cancer mortality from 1979 to 2000 showed that

the lung cancer mortality rate among men rose from 7.73

per 100 000 to 12.13 per 100 000, representing a 57%

increase. Among women it rose from 2.33 per 100 000

smoking cessation and tobacco product regulation.
To this end, the programme was structured to systematize
different kinds of educational activities and to mobilize

legislative and economic action with a view to creating a

favourable social context that would:

to 5.33 per 100 000, which represented a 134% increase

— reduce social acceptance of smoking;

(Ministerio da Saude do Brasil/lnstituto Nacional de

— reduce the social stimulus to smoking initiation by

Cancer, 2003).
In 1989, a national survey on health and nutrition showed

that smokers comprised 32.6% of the population over 15
years of age (IBGE, 1989). There were nearly 28 million
smokers in the group over 15 years old. Among them,

16.7 million were males and 11.2 million were females

youth;

— reduce the social stimulus that makes it difficult for
smokers to quit;

— protect the population from the hazards of passive
smoking;

— reduce access to tobacco products by minors; and

(Ministerio da Saude, 1998). The Ministry of Health is

developing a new, nation-wide survey in 26 states and in
the Federal District, The national domicile survey on risk

— increase availability and accessibility to smoking cessa­
tion support.

behaviour and referred morbidity related to non-com­

In addition to these actions, it was necessary to develop a

municable diseases. It will include 53 987 people in 18

strategy that would ensure that these efforts had a nation­

794 households and provide a new tobacco-use profile in

wide reach. Therefore, the process of building a network

Brazil.

with State and municipal health offices was begun. With

The monitoring of per-capita cigarette consumption shows
a reduction of over 32% when comparing the annual per-

capita consumption in 1989 and in 2001 (including con­

sumption estimates of the black market). In 1989 annual
per-capita cigarette consumption was 1 772 whereas in
2001 it was 1 194.

In 2001, a survey among 2 479 people living in Rio de

Janeiro city (Ministerio da Saude/ Institute Nacional de

CSncer, 2002b) showed that smoking prevalence had
decreased from 30% in 1989 to 21% in 2001.

the support of this network, a national action plan for
tobacco control has been carried out throughout the coun­

try. To prepare human resources from state and municipal
health offices to manage the programme at the local level,

INCA launched a capacity-building process in 1996 for
programme management. Today the programme manage­
ment is shared among all 26 States, the Federal District
and over 3 500 municipalities.

Considering that one of the most important components

of tobacco control action is socialization of scientific
knowledge on the hazards of tobacco, the programme

At the same time, Brazil is the world's third-largest tobacco

has sought to develop different kinds of efforts towards

producer, after China and India. It is also the world's leading

this goal. It has been disseminating information through

3

World Health Organization

campaigns and the mass media as well as engaging in

the blue, gold and red pack design for the brand Viceroy

continuous educational interventions directed at opinion

Rich Light. Phillip Morris's successful brand Merit connotes

leaders, such as teachers and health professionals, using

a "flamboyant, young-in spirit- image (to offset low tar's

school-, health unit- and workplace-based programmes.

dull image) with big, yellow, brown, and orange racing

Within this context, one of the most important strategies

stripes" (Pollay & Dewhirst, 2001).

employed to reach the smoker is the dissemination of
information through tobacco product packs.

Why tobacco product packs are used to
inform consumers about tobacco risks

Tobacco companies also recognize certain elements as key

to the product’s acceptance. One of them is psychological
and another is the product's ability to deliver the physi­

ological stimulus of nicotine.
As tobacco industry documents acknowledge, the market­

According to data presented by the World Bank (1999),

ing strategies are enhanced by nicotine dependence and

people’s knowledge about the health risks of smoking

create a very strong relationship between the smoker and

appears to be partial, especially in low- and middle-income

the packs of his or her preferred brand. Cigarette packs are

countries, where information about these hazards is lim­

present at every moment of a smoker's life, in situations of

ited. Today, 80% of the global consumption of tobacco

pleasure and satisfaction as well as in moments of sadness

is concentrated in low- and middle-income countries. In

and conflict. Many times the smoker lights his or her ciga­

China, where 25% of world's smokers live, 61% of adult

rette as a reflex, and several social cues, such as drinking

smokers surveyed in 1996 believed that cigarettes did

coffee, reading, creating intellectual works, driving, and

them "little or no harm" (World Bank, 1999).

others, function as triggers to this act. (Henningfield et al.,

For over a century, cigarette smoking has been advertised

1993; Balfour & Fagerstrom, 1996).

and promoted through different strategies to target dif­

Within this context, obtaining knowledge about smok­

ferent people in their different aspiration of happiness and

ing risks and their dimensions is one of the first steps of

fitness. This reality has enabled the creation of a positive

the cognitive behaviour approach for smoking cessation.

representation of smoking and a favourable social context

Other components can develop strategies to break the

for the growth of smoking. As part of these strategies,

automatic behaviour of smoking by creating obstacles.

cigarette packs have been used as an important way of

This can be achieved by making access to tobacco packs

promoting and marketing to attract the smoker, through

and to smoking difficult or creating other kinds of internal

colours, shapes and brand names. Cigarette packs were

barriers, such as thinking about the negative aspects of

also used to send subliminal messages to tranquillize the

smoking. In order to deal with cravings and to maintain

smoker as the scientific knowledge about smoking risks

abstinence, many former smokers report using a strategy

began to increase in the last 50 years (Kozlowski & Pilliteri

of creating a mental image of a harmed lung or other

2001; Pollay & Dewhirst, 2001; Shiftman, et al., 2001).

organ, or the image of a loved one suffering from severe

One clear example is the fact that the tobacco industry
has tried for decades to introduce new brands as safer

tobacco-related illness, such as cancer.
Considering this context, it is clear that tobacco products

choices, using the tactic of pack colours and product

packages could function as an important vehicle for risk

imagery to communicate the idea of "lightness".

communication. Besides reinforcing the knowledge and

The tobacco industry's own words tell how this works:

the dimension of the hazards of smoking, strong health

warnings on packs, mainly when illustrated by photo

Red packs connote strong flavour, green packs

images, could also undermine the attraction and the cues

connote coolness or menthol and white packs sug­

that make a smoker light a cigarette automatically in vari­

gest that a cigarette is low tar. White means sani­

ous situations during the day.

tary and safe. And if you put a low-tar cigarette in
a red pack, people say it tastes stronger than the

same cigarette pack in white (Pollay & Dewhirst,
2001).

In addition to breaking the automatic habit of lighting
up, the health warning with photo illustrations could also

destroy the positive aura that was created around cigarette
packs for many years. Likewise, it could have an important

Considering the pack influences over the smoker's choices,

influence in changing cultural beliefs about smoking, main­

Brown and Williamson tested 33 packs before choosing

ly in low- and middle-income countries, where information

Labelling and Packaging in Brazil

about hazards is limited. Towards this goal, the larger the

In 1989, INCA, under the auspices of the Ministry of

space the warnings occupy on the packs, the greater will

Health, assumed the responsibility of coordinating the

be their communication power. Therefore, it is vital that

National Tobacco Control Programme. On that occasion,

the strength of the warning messages be proportional to

following once again the example of other countries such

the magnitude of the risks.

as the United State of America and Canada, INCA started

On the other hand, it is also possible that many smokers
will refuse to look at these images, mainly those smokers

who do not want to quit as well as those who even want­
ing to, have trouble remaining abstinent. Some of them
will ignore the images. But even so, this measure will have

achieved its function. The pack will not exert the same

attraction as it did before. The smoker will be conflicted,
ambivalent, and in general, this is the first feeling that

leads the smoker toward the process of quitting smoking.

seeking to upgraded the regulation on the health warning.

In 1990, a new Ruling of the Ministry of Health no 731
increased the size of the warning on packs and in ads, pro­
hibited smoking in health units and banned the free dis­

tribution of cigarettes. The idea was to amplify the power
of the warning, making it more explicit about the risks of

tobacco use, since previous warnings were vague. Later, in
1995, the Inter-ministerial Ruling 477 (a ruling signed by
more than one Government ministry) replaced the previ­
ous regulation and the former warning was replaced by a

The evolution of health warning messages
on tobacco packs in Brazil*

varied and more specific series of health warnings.

In Brazil, the process of tobacco control began in 1985,

by the Health Ministry, the Communication Ministry and

when the Government, pressured by nongovernmental

the Justice Ministry. It was also a result of a negotiation

It is important to note that this new regulation was signed

organizations (NGOs) and medical associations, offi­

process that led to an agreement among these three min­

cially assumed the role of coordinating tobacco control

istries as well as trade associations representing the media

actions, and created the Health Ministry Advisory Board

and the tobacco industry. The presence of the tobacco

for Tobacco Control (Mirra & Rosemberg, 2001). Three

industry representative in the negotiation process was prob­

years later, and inspired by the example of the United

ably the result of the tobacco lobby and trade associations.

States of America, where the health warning insertion on

tobacco products had been approved by the United States

During the negotiation process, INCA, as the Ministry

Congress, it was possible to publish the first regulation on

of Health technical advisory board for tobacco control.

this issue in Brazil. Hence, in August 1988, the Ministry

presented various proposals for the new health warning

of Health Ruling no 4901 was published. This ruling rec­

messages, including one about nicotine dependence and

ommended restricting smoking in indoor public spaces,

pictograms to illustrate the warnings. At that time, despite

regulating tobacco advertising and requiring tobacco com­

all the accumulated scientific knowledge on the power

panies to include the health warning "The Health Ministry

of nicotine to create physical dependence, the tobacco

advises: Smoking is harmful to health” on all tobacco

industry, as usual, strongly denied the addictive nature of

product packs (cigarettes, cigars and pipe tobacco) as well

tobacco, and refused to agree to including the warning on

as advertisements. The ruling also required that the letters

the addictive properties of tobacco. On that occasion, the

be clear, legible, and written in contrasting colours. The

tobacco industry also exploited the uncertainty of the epi­

responsibility for ensuring that tobacco companies com­

demiological risk argument to avoid the use of more direct

plied with this ruling was given to the Health Ministry's

statements for the warning messages. It was a tough

Health Surveillance department and to regional health

negotiation, and neither the pictograms nor the message

offices.

about nicotine dependence passed as a result of the tobac­
co industry's resistance. In addition to this, the expression

This is a type of executive act that can be put into force

by any public authority and that can involve guidelines
regarding existing laws, rules, recommendations of gen­

eral character, rules for the carrying out of services or
any other act within its competence. It does not have the
power of a Federal law.

"can cause" was introduced in all messages emphasizing

the uncertainty of risks.

Therefore, this ruling was a result of an agreement and
had attached to it a commitment letter signed by the three

represented government agencies and by the representa­

tives of tobacco companies and media trade associations.

World Health Organization

Formerly secret, internal documents of tobacco companies
such as Philip Morris and British American Tobacco make
clear that industry executives were strongly prepared to

resist any attempt to advance health warnings. The follow­

Figure 1
Prior health warning in Brazilian cigarette packs before the
new warnings with pictures.

ing quote illustrates how the tobacco industry had been
preparing their executives to deal with health warning
issues, which they considered as a threat to their business.

We should resist the introduction of warning claus­

es on packs or advertisements on the grounds set

out in Position Papers. Additional arguments that
could be put forward in negotiations with authori­

ties are that in countries where warning clauses

are in force there is no evidence that they have
been effective in reducing cigarette consumption...
If faced with a warning clause, the wording of

which implies or states that cigarettes cause named

The Ministry of Health advises:

disease, we should resist it with all means at our

children begin to smoke when

disposal and never make this concession. If such

they see adults smokiing

wording becomes inevitable, we should do our

utmost to ensure that all warning clauses, irrespec­
tive of wording, are attributed to Government or
some other official body (British American Tobacco

Previous health warnings on Brazilian

Public Affairs, 1992)

cigarette packs before the introduction of

The new ruling defined certain graphic specifications for
the warnings such as type, size and the duration of the

new warnings with photo illustrations

Though it had not been possible to achieve all INCA pro­

warning’s sequential replacement. But it did not define the

posals due to tobacco industry tactics, there were some

responsibility for surveillance and applying penalties for

gains. For example, it was possible to replace the previous

non-compliance with the ruling. This enabled the tobacco

health warnings with different and more specific health

industry to interpret and apply it as the industry saw fit.

warnings in a rotating fashion. In addition, spoken warn­

Thus, the warnings were inserted on packs in a very dis­

ing messages were introduced following all tobacco ads

crete way, compromising their visibility, which achieved

on radio and TV. Considering that the previous regulation

another tactic that today is confirmed among millions of

only permitted its transmission in written form and that

pages of secret tobacco industry documents.

there was a significant level of illiteracy among the low-

This strategy is confirmed in another quote found in a

British American Tobacco (BAT) analysis of the Marlboro

income population, such changes in warning messages
represented one more advance within this difficult process.

The new warnings introduced are outlined below.

brand and distributed to its affiliated companies (including
Souza Cruz in Brazil). This analysis illustrates how deliber­

The Ministry of Health advises:

ately the tobacco industry had been working to reduce the

— Smoking can cause heart disease and stroke;

health warnings' visibility on packs. Among the analyses

of the characteristics of several packs of Marlboros, such
as design, consistency across the market - and over time,

the colour red, the way in which health warnings were
inserted was analysed:

— Smoking can cause lung cancer, chronic bronchitis,
and emphysema;

— Smoking during pregnancy can cause harm to

the baby;

— People who smoke get stomach ulcers more
...clever positioning and use of colour (discrete
gold) have ensured minimum impact on the overall
design and minimum legibility to the smoker. (British

6

American Tobacco Competitor Activity Report, 1994).

frequently;

— Avoid smoking in the presence of children; and
— Smoking cause severe harm to your health.

Labelling and Packaging in Brazil

Later, in 1996, Federal law2 no. 9.294/96 was published,

which grew out an agreement with tobacco industry

regulating different aspects of tobacco consumption,

and trade associations representing the media. Hence,

such as smoking in public places, tobacco product adver­

Provisional Measure no. 1814 followed by publication

tising and promotion and inclusion of health warnings on

of the Ministry of Health Ruling no. 695 in June 1999

the package labels of tobacco products. Consequently,

enabled the Health Ministry to render the language

this measure became stronger, as the former executive

of the health warning messages much stronger, and

measure (a ministerial ruling based on an agreement)

more direct and effective by removing the term "can

was replaced with a Federal law. The warnings defined

cause" from the messages. In addition to this improve­

in the prior ruling were retained. But the definition of the

ment, two new and stronger messages were introduced:

characteristics of the lettering remained vague since it

"Nicotine is a drug that causes dependence" and

only required that the warning message be placed on one

"Smoking cause sexual impotence". At this point there

of the lateral sides of packs in a legible and highlighted

was no negotiation and the new messages were as out­

form. There were not any other details specified, such

lined below.

as size and colours of letters and background. There was

also no definition of responsibilities for surveillance and

The Ministry of Health advises:

applying penalties in the event of non-compliance with

— Smoking causes lung cancer;

the law.

In 1999, thanks to the personal commitment of the
Ministry of Health, this measure was strengthened.

Federal law no. 9.294/96 was modified by Provisional
Measure3 no. 1814, which gave the Ministry of Health

—■ Smoking causes heart infarction;

— Nicotine is a drug that causes dependence;

— Smoking causes sexual impotence; and
— Children start smoking by seeing adults smoking.

the power to determine the health warnings. It is impor­

tant to remember that until that time, the language of

However, the law still lacked force when it came to the

the messages was that of the previous message in 1995,

warning's graphic specifications, namely, the size and

space it should occupy on packs and the colours. Nor was
responsibility assigned for inspection and punishment. The
2 Before becoming a federal law any legislative initiative has

strength of the language was not matched by the quality

to be submitted for the approval of the National Congress

of the warning's graphics. Exploiting these loopholes, the

(House of Deputies and Senate). The Constitution of Brazil

tobacco industry continued to add the warning messages

allows an initiative of a complementary or ordinary law

in muted colours and small letters.

to originate from any member of the National Congress,
President of Republic, Federal Supreme Tribunal, Superior

In other words, for the consumers, the visibility of the

Tribunals, the General Procurator of Republic and from

health warnings on the packs continued to be poor. The

any Brazilian citizen. This law came from a Bill originated

way in which the health warning messages were pre­

by a federal deputy supportive of tobacco control in Brazil.

sented suggested that the message was of little import.

When a legislative initiative comes from the executive

branch, the National Congress can either approve or not

approve it. But depending on the matter of the bill, the

The new health warnings with photo
in Brazil

non-approval does not prevent the executive branch from

converting it into a legislative decree.
3 For reasons of relevancy and urgency, the President of the

Republic can adopt a provisional Measure, that is, a legis­
lative instrument with the power of law. Each provisional
measure is valid only for 30 days. After its publication it

can be valid for more than 30 days, and after 45 days
it is automatically sent to be voted on by the National

Congress and Senate, when it can be converted into a
federal law or dismissed.

Key steps

Other important new advances were possible after the
National Tobacco Control Programme gained an important
ally in the field of tobacco product regulation. Through

Federal law no. 9.782 enforced in January 1999, the

National Health Surveillance Agency, Agenda Nacional de
Vigilancia Sanitaria (ANVISA), was created and within its

authority, fell the control, inspection, advertising and pro­
motion of tobacco products.

0

World Health Organization

Also in 1999, the National Commission on Tobacco

smoking risks during pregnancy, smoking risks for babies

Control4 in Brazil was formed by Presidential Decree no.

whose mothers smoked during pregnancy, smoking risks

31365 (13 August 1999). The commission's objective was

for oral diseases, including cancer and risks to breathing

to serve as adviser to the Brazilian Government during

impairment that smoking causes. It also prohibited the

the negotiation process of the Framework Convention on

use of any kind of external wrapping or devices that could

Tobacco Control (FCTC).

impair or make it difficult to see the warnings.

This new commission enabled the measures that were pro­

Regarding the size of the health warning messages with

posed during the negotiation of the FCTC process and the

photo illustrations, ANVISA Resolution determined that

health warnings with illustrations that Canada adopted to

they had to occupy 100% of one of the largest sides of

be recommended by the National Commission on Tobacco

cigarette packs. This decision was due to the small size of

Control in August 2000 to the President of Brazil.
Hence, recognizing the importance of this measure for
public health, in May 2001, the President of Brazil pub­

lished Provisional Measure no. 2.134-30. This regulation
complemented the above-mentioned legislative back­

ground on tobacco control, determining that the health
warnings on tobacco products packs would be illustrated
by photo images. At the same time, the publication of

cigarette packs in Brazil when compared to Canadian ones.
The trials had shown that the model Canada adopted,
in which the images occupy 50% of both larger sides of
packs, would not fit well on packs in Brazil. This is because

they are smaller than Canadian ones, and the images' vis­

ibility could be compromised. In addition, in Brazil the only
language spoken is Portuguese. Hence, there was no need

to put the messages in different languages.

ANVISA resolution no. 104 defined the kind of warnings

In March 2001, before publishing the health warnings

and images that would illustrate them, as well as their

with the photo illustration measure, ANVISA had also

graphic specifications, such as colour and size patterns,

published another important measure regarding package

the placement and the space that they had to occupy

labelling, ANVISA Resolution no. 46. It established that

on tobacco product packs. It also provided the tobacco

the maximum yields for tar, nicotine and carbon monox­

industry with models of images and warnings, through the

ide on mainstream smoke for commercialized cigarettes

Internet: www.anvisa.gov.br (Figure 2).

in the country had to be ten milligrams per cigarette, one

The ANVISA Resolution added four more warnings to
the five previous ones. The new warnings were related to

milligram per cigarette and ten milligrams per cigarette

respectively. It also prohibited the use of descriptors such
as light, soft, low yields, and other terms that could give

the consumer a false sense of security about the products.
4 The National Commission on Tobacco Control was cre­

This measure also required tobacco companies to insert

ated in August 1999 by Presidential Decree no. 3136.

information on packs about these yields, and an additional

Its function was to provide support for the President of

and non-rotating health warning "There is no safe level

Brazil on the Brazilian position during the negotiations

for consuming these substances". This non-rotating warn­

of the Framework Convention on Tobacco Control. This

ing had to occupy 100% of one of the lateral pack sides.

Commission has representatives from the Health Ministry,

Finance Ministry, Industry and Trade Ministry, Agriculture
Ministry, Agrarian Development Ministry, Justice Ministry,

Foreign Relations Ministry, Labour and Employment

Ministry and Education Ministry. The Ministry of Health is

the president of the Commission, and the National Cancer
Institute is its executive secretariat.
5 The term legislative d'ecree is used to designate execu­
tive measures that have the power of law without being
submitted to the approval of the Congress. The Brazilian

constitution allows the President of the Republic to pub­
lish legislative decrees on specific matters, such as those
related to public finances and social security

It must be underscored that ANVISA's role in surveillance
and applying penalties over non-compliance enhanced this
measure's power. The penalty for non-compliance includes

admonition, product seizure and a fine that can range

from 1 410 000 reais (USS 470.00) to 7 250 000 reais
(USS 2 416 000). In cases of recurring non-compliance,
companies can be charged two, three and four times these

amounts, depending on the number of relapses.

Labelling and Packaging in Brazil

Figure 2
The labeling regulation - on Brazilian tobacco products. Health warning with images illustrating them and information about

cigarette emission followed by the message "There is no safe level for this substance consumption:”

0 Mimstdrio da Siude alberta-

0 Mtnstfrio da Saude advene

FUMAR CAUSA
CANCER DE PULMAO

FUMAR CAUSA
INFARTODOCORACAO

<4^ ■
*■ aiTH-Si

"Smoking causes bad

"Smoking causes

"Smoking causes

"Children begin to

breath, teeth loss

lung cancer"

heart attacks"

smoke when they

and mouth cancer"

see adults smoking"
0 Minisldrio da Salido adwyte:

OMHstirio da Saul* adverts

FUMAR NAGRAVIDEZ
PREJUDICA 0 BEBE.

FUMAR CAUSA
IMPOTENCIA SEXUAL

"Smokers are short

"Smoking during

"Nicotine is a drug and

“Smoking causes

of breath"

pregnancy harms

causes dependency"

sexual impotence"

your baby"

"Cigarette smoking by pregnant
women causes premature births,

"There is no safe level

underweight babies and babies

for these substances

liable to have asthma"

consumption"

9

World Health Organization

Tobacco product packs - vehicles to

was first established for enforcing the measures. During

stimulate and give support for smoking

the negotiation process, the tobacco industry also tried to
downgrade the quality of the warning graphic specifica­

cessation

Since INCA had created a hot line to lend support for
smoking cessation, the ANVISA Resolution also required
the insertion of the hotline phone number in tobacco
product packs. This hotline for smoking cessation, Disque

Pare de Fumar, (Call to quit smoking) complements the

stimulus for smoking cessation generated by the health
warning on packs.

tions required by the ANVISA resolution. Using the argu­
ment that they lacked the graphic capabilities to produce

the quality of graphics the measure required on such short
notice, representatives of major tobacco companies in

Brazil asked to use only two colours for the warning image
printing. They also requested a two-year timeframe to

revamp their graphics production to comply with the new
regulation's graphic requirements.

Through this communication channel, people can receive

advice on smoking cessation, and also messages support­
ing and enhancing the client’s self sufficiency in quitting
smoking. Since the National Tobacco Control Programme

is building a national network of services for supporting
smoking cessation in the public health system, the hot­

Another argument used by the tobacco industry was that
the costs of the new warnings would have to be passed

on as product price increases, thus increasing the possibil­

ity of smuggling and counterfeiting, and lost revenues for
the Government.

line service maps these service locations to show smokers

Following negotiation, February 2002 was targeted as the

where they can receive a more intensive approach to quit­

deadline for the enforcement of both ANVISA measures.

ting smoking within the health system.

So, despite being published in 2001, both measures came

into force only in February 2002.
Tobacco industry reaction
The tobacco industry was taken aback by the

Government's adoption of this measure on health warn­
ings with photo illustrations in 2001, since there was no
previous negotiation. However, soon after the measure's

announcement, tobacco companies approached the

Government to negotiate the three-month timeframe that

As tobacco companies received more time to comply with
the new rules, they exploited this time lag to develop
tactics to circumvent the prohibition of the use of brand

descriptors like 'light', 'mild', low yields'. During the peri­
od between the publication of ANVISA's resolution (March
to May, 2001) and their enforcement (February 2002), the

Figure 3
Example of brand marketing strategies used in order to create a link between brand descriptors and the color packs variations
in a same brand family.

Soon your Derby is going to change the

name of its versions King Size, Suave (Mild)
and Lights. Now besides the different yields,
the traditional colors are going to mark the

difference among them:
Red for those that prefer a more intense taste
Blue for those who want mildness

Silver light taste, the lighter of the family

The names have changed, but Derby is still
the same, with the same quality, leadership

and taste that conquered Brazil.
DEJUSy

&

Labelling and Packaging in Brazil

Figure 4
Example of advertising cards inserted into cigarette packs by tobacco companies after the new health warning with photos began
to circulate in Brazilian market____________________________________________________________________________________

FREE has changed its clothes

biggest tobacco companies developed brand marketing

after the new packs began to circulate in February 2002.

strategies to create a link between brand descriptors and

Some companies began to put ad inserts into packs with

pack colours.

At first, they invested heavily in diversification of the col­
our packs to represent variations within the same brand

the same shape and size of the photo warnings, in order
to allow the smokers to use them to cover the warning
images

family. For example, for the Hollywood brand, one of the

During 2002, tobacco companies did not completely com­

most popular in Brazil, they created the blue and green

ply with the graphic specifications established by ANVISA.

menthol variants, in addition to the regular red colour

Despite the fact that the ANVISA resolution required the

packs. Besides creating different pack colours for each

messages to be written in white letters on a black back­

brand family, during the same period they circulated pam­

ground, the packs began to circulate with different back­

phlets with messages to consumers within the packs of

ground colours. For example, for red packs there was a red

these brand variants, introducing them as the new version

background, for blue packs, a blue background, for gold

of the light variation of the brand (Figure 3). The idea was

packs, a gold background and so one.

to prepare the consumers to link the colours of the packs
with the notion of light, mild or low yields. One of the

Government counter reaction

managers of the companies sent a letter to INCA inform­

As ANVISA began to apply penalties, the tobacco indus­

ing it of the strategy's aim:

try looked to ANVISA to renegotiate the timeframe for

...Due to the prohibition of the descriptors use,
the company will be using different colours for the

different versions of a same brand family, as, for
example, the Hollywood family, that has the RED,

BLUE and GREEN MENTHOL versions, to allow the
consumer to identify his preferred brand. The yields

of each version are printed on the lateral side of

the packs... (Gava JP, unpublished data, 2001)
Tobacco companies also adopted another strategy to cir­
cumvent the new health warnings with photo illustrations,

adopting the colour quality required by the measure. The
argument used was that they still were not prepared to
have the quality colours required by the regulation and
that they could not reproduce the black colour required as

background to the white letters of the warnings.
Therefore, ANVISA renegotiated the timeframe and pub­

lished another resolution in January 2003. With this new
resolution, ANVISA also modified its prior resolution, no.
46 and passed it to require tobacco companies to insert

non-rotating warnings on one of the lateral sides of tobac-

World Health Organization

Figure 5
Number of calls to the Hot line - Call to quit smoking - before and after the insertion of the hot line number in packs as part
of the measure of health warning with photos. Statistics from June 2001 to June 2002

co products. They were: "This product contains more than

With the media's intense coverage during the measure’s

4 700 toxic substances and nicotine that causes physical

enforcement, many cigarette sellers interviewed by the

and psychological dependence. There is no safe level for

media reported that there were three images that smokers

consuming these substances ”. It also prohibited the use of

rejected most during sales. Most rejected was an image of

messages such as “only for adults" and "product for 18

a baby with tubes, showing the harm induced by smok­

years older or more" and similar messages that tobacco

ing during pregnancy. The second most rejected was the

companies used to place "voluntarily" on the other lateral

image of a women in an intensive care centre for lung

sides of tobacco packs. Realizing that the message "for

cancer, and the third most rejected was the image of a

adults only" clearly has a strong appeal for adolescents,

couple in relation to sexual impotence. Of course these

and reinforces the identification of cigarette packs with

perceptions need to be further confirmed by a survey that

the adult world, this new resolution required tobacco

is being prepared by the Health Ministry.

companies to replace this 'voluntary and ambiguous' mes­
sage with a new one targeting tobacco sellers. The new

message read: "Sale prohibited to minors of 18 years old,
Law 8.069/1990 PENALTY: 6 months to 2 years in jail and
fine". This regulation will enter into force in January 2004,

when tobacco companies must be prepared to fulfil all of
the health warning regulation's graphic requirements.
Public reaction

Conversely, an independent poll conducted in April 2002

by the Institute Datafolha showed positive results. The poll
involved 2 216 people over 18 years old in 126 municipali­

ties. It showed that 76% of those interviewed approved

of the measure. Of the smokers, 73% approved of the
measure and 67% said the images increased their desire to
quit smoking. Within the low-income smokers group, 73%

said the new warnings increased their desire to quit smok­
ing, and within the group from 18 to 24 years of age 83%

The announcement of the health warning with the photo

approved of the measure3. Other evidence of a positive

illustration measure galvanized public opinion. There was

impact could be seen in the statistics of the hotline Call to

heavy media coverage and considerable public discussion

Quit Smoking. After printing the number in the packs, the

on this subject.

number of calls increased progressively (Figure 5).

6

See web site: http://www1.folha.uol.com.br/folha/
datafolha/po/campanha_fumo_22042002a.shtml.

In addition to this measure, after the legislation’s enforce­
ment, an interview with 32 664 people who called the
hotline showed that 92.62 % knew about the hotline

Labelling and Packaging in Brazil

number through the cigarette packs. A poll conducted two

spoken warnings on the dangers of tobacco use following

months after the enforcement of this measure among peo­

smoking ads on the radio and TV were possible .

ple who called the hot line showed that 67% of smokers
became willing to stop smoking when they saw the new

warning with the photos.

Later in this process, a sequence of key legislative steps

culminated with the recent advance of stronger warn­

ings accompanied by photos. One of these steps was the

On the other hand there were some polemics around the

conversion of the executive ruling on health warnings into

warning images, such as certain people and some associa­

a federal law in 1996. This was the result of the special

tions claiming that such a measure amounted to an inva­

engagement of the Health Ministry and a deputy that

sion of smoker privacy. A black people's rights association

presented a bill of law that was approved by the Congress

decided to sue the Health Ministry because one of the

as Federal Law no. 9.294. The second and third steps took

health warnings used an image of a black man to illustrate

place in 1999. A provisional measure gave Health Ministry

the dependence on nicotine. Their argument was that this

the power to define the health warnings and a federal law

was a racial prejudice because it stimulated the association

created the National Health Surveillance Agency (ANVISA),

of black people with drug use and criminality.

and included the control and inspection of tobacco prod­

Conversely, the Health Ministry has been receiving con­
siderable support and feedback from Brazilian citizens
through the Internet and hotline. Some people suffering
from tobacco-related diseases have even offered their

images to illustrate the health warnings.

ucts along with their advertising and promotion among its

responsibilities. These historical key steps helped to create

a positive context for stronger tobacco product regulation
including, its labelling.

In addition to these measures, the Framework Convention
on Tobacco Control (FCTC) negotiation process and

Conclusion

the Brazilian Government’s involvement in this process
strengthened the political will to regulate tobacco products.

In Brazil, tobacco control legislation has advanced over
the years and has seemed to follow an increasing level of

Within this process, the National Cancer Institute (INCA),

maturity within the Brazilian population concerning smok­

the Health Ministry body and coordinator of the National

ing risks. The National Tobacco Control Programme played

Tobacco Control Programme, and later the executive sec­

a vital role in constructing an educational base through

retariat of the National Commission on Tobacco Control,

campaigns, continuous efforts to educate opinion leaders

played a vital role in articulating, lobbying and lending

like teachers, health professionals, legislators and media,

technical support to executive and legislative measures.

and developing a partnership network. This network,

which included government organizations and NGOs,

At the same time, taking account of the measures that

were presented for FCTC negotiation process, and the

seemed to have been pivotal in raising national conscious­

positive experience of Canada in adopting health warn­

ness on tobacco's harm and in mobilizing a change in the

ings with photo illustrations, the National Commission on

social representation of smoking. Educational measures

Tobacco Control of Brazil recommended to the President

and legislation have been mutually supportive. At the

of Brazil the adoption of a similar measure.

same time, educational measures have been creating an
advocacy network that supports and stimulates imple­

Its important to recognize that the FCTC language and

menting legislation for tobacco control. The Brazilian legis­

the whole process of its negotiation created a climate of

lative environment has been enhancing and reinforcing the

legitimacy for some advances that were much harder to

educational measures developed by the programme.

achieve before the FCTC's existence.

Within this context the Brazilian legislative process began

What is more, access to millions of tobacco company

inserting warning messages on tobacco packs in 1988

internal documents proving their real intentions and strate­

through executive measures (Health Ministry rulings). As

gies, has contributed to gaining advances for tobacco con­

scientific knowledge of the harm done by tobacco gained

trol more easily than in years past. Today, tobacco control

broad exposure through public campaigns and the activ­

advocates can be better prepared to face tobacco industry

ity of scientific bodies, it was possible to make additional

arguments and strategies to counteract tobacco control

advances. Incrementally, and despite tobacco industry

actions. They can also better understand the arguments

opposition, advances like rotating different warnings, and

and strategies the tobacco industry uses to circumvent

World Health Organization

any attempts to implement tobacco control measures, as

well as their strategies to create positive relationships with

government authorities and legislators to convince them to
not adopt tobacco control measures.

The effort to control tobacco has not been an easy task.
One very important step is to build a supportive context of

International Labour Office (2003) Employment trends in the

tobacco sector: challenges and prospects. Report for discussion

at the Tripartite Meeting on the Future of Employment in the
Tobacco Sector, Geneva.
Gava JP (2001) Unpublished data.

Kozlowski LT and Pilliteri JL (2001) Beliefs about "light” and

public opinion. In spite of all the tobacco industry lobby­

"Ultra light" cigarettes and efforts to change those beliefs: an

ing, today in Brazil, a bill of law is much more likely to be

overview of early efforts and published research. Tobacco Control

approved than it was 15 years ago. Today, Brazilians not

an International Journal, Vol. 10, Supp 1:4-11.

only support measures for tobacco control, they charge

the Government with adopting stricter measures.

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Balfour DJ and Fagerstrom KO (1996) Pharmacology of nicotine
and its therapeutic use in smoking cessation and neurodegenerative disorders. Pharmacology and Therapeutics 72 (1):1-30.

Bialous SA (2000) Tobacco industry document analyses presented
during the Forum about Media and Tobacco on 31 May 2000,
Sao Paulo, Brazil.

Ministerio da Saude do Brasil/lnstituto Nacional de Cancer (2000)
Funda<;ao Getulio Vargas. Cigarro Brasileiro. Analises e Propostas

para Redugao do Consumo, Rio de Janeiro.
Ministerio da Saude do Brasil/lnstituto Nacional de Cancer

(2002a) Estimativas da incidencia e mortalidade por cancer no

Brasil.
Ministerio da Saude do Brasil/lnstituto Nacional de Cancer
(2002b) Smoking profile in Rio de Janeiro 2001-preliminary
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British American Tobacco (1992) Public Affairs, Topics in Smoking
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Ministerio da Saude (1998) Falando sobre Tabagismo. Secretaria
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British American Tobacco Competitor Activity Report (1994) Bates

Coordenacao Nacional de Controle do Tabagismo e Prevenjao

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Primaria de Cancer (Contapp), Rio de Janeiro, 3* ed.: 33.

Campaign for Tobacco Free Kids (2001) Golden Leaf. Barren

Ministerio da Saude do Brasil/lnstituto Nacional de Cancer (2003)

Harvest The Costs of Tobacco Farming. Washington, D.C.

Estimativas da incidencia e mortalidade por cancer no Brasil.

Fiore MC et al. (1996) Smoking Cessation. Smoking Cessation

Guideline Panel. In: Clinical Practice Guideline. U.S. Department

Mirra AP and Rosemberg J (2001) A historia da luta contra o tabag­
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Heath Care Policy and Research, Number 18, AHCPR Publication

no. 96-06292.

Niaura R et al. (1999) Cue exposure treatment for smoking
relapse prevention: a controlled clinical trial. Addiction, 94(5),

685-695

Fiore MC et al. (2000) Treating Tobacco Use and Dependence.
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Orleans CT et al. (1993) Minimal-contact quit smoking strate­

Human Services, Public Health Service, Agency for Heath Care

gies for medical settings. In: Nicotine Addiction. Principles

Policy and Research, June.

and Management, Orleans CT and Slade J, New York, Oxford
University Press.

Henningfield JE, Cohen C and Pickworth WB (1993)
Psychopharmacology of nicotine. In: Nicotine Addiction.

Pollay RW and Dewhirst T (2001) Marketing Cigarettes with Low

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Machine-Measured Yields. In: Smoking and Tobacco Control.

Oxford University Press.

Risks Associated with Smoking Cigarettes with Low Machine-

Measured Yields of Tar and Nicotine, National Institutes of
IBGE (1989) Instituto Brasileiro de Geografia e Estatistica, Pesquisa

Health. National Cancer Institute. Monograph 13, pp 199-235.

National sobre Saude e Nutrijao (PNSN.
Shiftman S et al. (2001) Smoker’s beliefs about "Light" and “Ultra

IBGE (2000) Instituto Brasileiro de Geografia e Estatistica, Censo

Light" cigarettes. Tobacco Control, 10 (Suppl I): 117 - i 23.

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14

Economics of Tobacco Control, Washington, D.C.

Jordan: Mass Media Campaign
Combating Smoking Requires Serious
Commitment and Not Just Words
Suha Philip Ma'ayeh
Journalist, Jordan Times

WO
Wf World Health Organization

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

WHO Regional Office for Africa (AFRO)

WHO Regional Office for Europe (EURO)

Cite du Djoue

8, Scherfigsvej

Bolte postale 6

DK-2100 Copenhagen

Brazzaville

Denmark

Congo

Telephone: +(45) 39 17 17 17

Telephone: +(1-321) 95 39 100/+242 839100
WHO Regional Office for South-East Asia (SEARO)
WHO Regional Office for the Americas / Pan
American Health Organization (AMRO/PAHO)

World Health House, Indraprastha Estate
Mahatma Gandhi Road

525, 23rd Street, N.W.

New Delhi 110002

Washington, DC 20037

India

U.S.A.

Telephone: +(91) 11 337 0804 or 11 337 8805

Telephone: +1 (202) 974-3000
WHO Regional Office for the Western Pacific
WHO Regional Office for the Eastern

(WPRO)

Mediterranean (EMRO)

P.O. Box 2932
WHO Post Office

Abdul Razzak Al Sanhouri Street, (opposite Children's
Library)
Nasr City, Cairo 11371

Egypt
Telephone: +202 670 2535

2

1000 Manila

Philippines
Telephone: (00632) 528.80.01

Jordan: Mass Media Campaign Combating Smoking Requires Serious Commitment and Not Just Words

Introduction

The target group was the adult population. The first of
November was designated as a 'Jordanian No-Tobacco

Tobacco use is a growing problem in Jordan, a developing

Day', as part of a smoke-free Arab week, an idea devel­

country with a population of 5.3 million (1). Each year,

oped by the Arab League. This theme was highlighted

cardiovascular diseases are responsible for about 42% of

in State radio and TV. Both radio and TV hosted experts

all deaths in Jordan and cancer is responsible for 13% (2).

for an entire week, promoting cessation. Talk shows and

Smoking has been found to be the main factor contribut­

discussions made reference to the health consequences

ing to these health problems.

arising from consuming different types of tobacco in

In 2000, Jordan's National Cancer Registry recorded an

average of 3 360 new cancer cases. Lung cancer was the
most prevalent type, with 223 cases. Of these cases, 185

lung cancer patients were smokers.
a

"

Smoking is highly prevalent among adolescents. Jordan’s
Global Youth Tobacco Survey (GYTS) conducted in 1999

showed that 19.3 % of students between the ages of 13
and 15 (25% of male students and 14.5 % of female stu­

dents) are smokers. This is primarily due to their imitating
adults, peer pressure and easy access to cigarettes. This is

a high percentage in a country where half of the popula­
tion is under the age of 18 (1).
Another study on morbidity, conducted in 1996, revealed

that the prevalence of smoking among Jordanian adults

over 25 years was 26.9% (4). Almost 48% of males and

10.2% of females smoked daily . However, only 9.7% of

the adult population was able to quit.



cigarettes, the hisheh, the pipe and the 'hubbly bubbly,'

known as 'argileh'. Addressing the problem of disease

caused by second hand smoke, Jordan TV repeatedly aired

an ad showing a healthy young woman turning into a
sickly person with decaying teeth.
Part of the counter-marketing efforts included leasing 60

billboards that were set up in different parts of the capital
for three months. They highlighted the 1977 anti-smok­

ing regulation that restricts smoking in public places and

on public transport. Counter-advertising in print included
free-of-charge ads, which continuously appeared in official

newspapers emphasizing the antismoking regulation via

'No smoking' signs or text.
Another part of the media campaign comprised posters

and brochures illustrating the health risks of tobacco use.
They were distributed to university students, sports clubs,
maternity and child health-care centres as well as women's

societies. Posters focused on presenting toxic and carci­

National figures reveal that smokers in the Kingdom spend

nogenic effects of tobacco use. One such poster detailed

an estimated JD 250 million1 (2) annually on tobacco

over 400 poisonous substances contained in a cigarette.

products, or some 4% of the country's national gross
domestic product. Smoking the water pipe or Argileh is

Another poster sought to promote a smoke-free culture,

also becoming a very popular practice in tobacco use.

Policy intervention___________________
In November 2001, the Ministry of Health (MOH),
through its tobacco control programme, started a three-

urging smokers to "Break Free" by choosing to breathe.
Despite these efforts, no studies were conducted on the

ratio of pro- to counter-advertising to assess whether the

media campaign promoted cessation and decreased the
likelihood of initiation. However, data available in the
global youth tobacco survey (GYTS) included a survey on

month media campaign to fight tobacco use in the coun­

pro-cigarette advertising in 1999.

try. The campaign sought to counter the influence of pro­

The GYTS found that 81 % of 7th to 9th graders were

tobacco marketing and advertising by promoting health

exposed to indirect pro-cigarette marketing and advertis­

awareness of the hazards of smoking, exposure to second­

ing. Of the 3 912 students surveyed, 61 % of them saw

hand smoke and the existing tobacco-related legislation. In

pro-cigarette ads in newspapers and magazines, 59% saw

fact Jordan was one of the first countries in the region to
introduce an anti-smoking regulation in 1977 by slapping

sessed an object with a cigarette brand logo and 27% were

a ban on smoking in public places and on public transport

offered cigarettes by a tobacco company representative.

pro-cigarette commercials during sport shows, 33% pos­

as well as prohibiting tobacco advertising. But enforcement
was lax over the years.

The campaign was carried out through paid television ads,
radio official newspapers, billboards and publications.

1 The Jordan dinar Is equivalent to about SUS 1.42.

World Health Organization

Other tobacco control measures included imposing restric­

Steps toward implementation

tions on tobacco sale for minors as part of a Juvenile
Monitoring Legislation, effective as of 1 November 2001.

Fighting tobacco use in the country was intensified in

Penalties for minors include a JD 20 fine for a first-time

2001, the year Jordan began taking part in negotia­

violation, which would double if the offence were to be

tions for the recently adopted Framework Convention on

repeated. The vendor would face a JD 100 fine and a jail

Tobacco Control (FCTC).

sentence of up to one year. The legislation was announced
on radio and TV and published in Official Gazette one

month before it became official.

As a first step, the Health Ministry in cooperation with

UNICEF and the World Health Organization (WHO)
established a multisectoral steering committee, known as

At the grassroots level, a school-based pilot project that

the National Committee for Anti-smoking. Its members

involved peer education on tobacco control was applied in

were drawn from the Ministry of Health and the Ministry

28 schools during the scholastic year 2002-2003. Seventh

of Religious Affairs, UNICEF, JASS, United Nations Relief

to ninth graders were provided with anti-smoking educa­

and Works Agency for Palestine Refugees in the Near East

tional kits comprising thought-provoking exercises, puzzles

(UNRWA) and the Jordan Medical Association, and indud-

and an evaluation form to assess their comprehension.

ed a lawyer. The Committee was in charge of supervising

The project, dubbed "Rising Generation without Smoking"
was first introduced by the United Nations Children’s

Fund (UNICEF) and the Jordanian Anti Smoking Society

tobacco control activities.

Later, the Health Ministry adopted a tobacco control

programme and appointed personnel to run it during the

(JASS) in cooperation with Ministry of Education. It was

second half of 2001. The programme acted as a coordina­

implemented in 17 schools throughout 2002-2003. As a

tor between Government ministries and funding organiza­

result of its popularity, the Health Ministry and UNICEF

tions to implement anti-tobacco activities. The tobacco

ran a parallel project adopting the theme "Smoke Free

control programme then launched a three-month media

Schools" using the same educational material and covered

campaign on 1 November 2001, which was designated as

11

schools. Plans are under way to expand the school pro­

gramme to include an additional 50 schools for the scho­

lastic year 2003-2004.

In addition, an anti smoking clinic was set up in late 2001

a Jordanian No Tobacco Day.
Subsequently, the steering committee drafted a five-year

tobacco control strategy, with eight goals and a plan of
action. On 31 May 2002, World No Tobacco Day, the

to promote cessation among smokers, which is supervised

Health Minister endorsed the strategy and it was put into

by the tobacco control programme. The clinic offers free-

action. The main objectives of the tobacco control strategy

of-charge counselling and nicotine inhalers for those who

were based on elements of the FCTC, which Jordan adopt­

wish to kick the habit. It will include a hotline as part of

ed on 21 May 2003. The strategy was comprehensive

its future services. Until last year, the clinic offered coun­

and provides for a general ban on tobacco advertising, a

selling for 70 adult patients, 10% of whom quit smoking

raising of public awareness on the hazards of tobacco use,

without resorting to any anti-smoking drugs. There are

enforcement of legislation, and encouragement of smok­

plans to set up clinics in the country's 12 governments,

ing cessation, among others.

once funding is available.

Establishing the tobacco control programme and the

A series of tobacco-related awareness workshops were

endorsement of the five-year tobacco control strategy

conducted to educate the media as well as personnel from

were crucial steps toward reaching the final stage of the

both the Ministries of Health and Justice about tobacco-

intervention policy. This is the first time ever that Jordan

related legislation. An annual contest for volunteer work­

has adopted a tobacco control programme that is respon­

ers adopted the negative effects of smoking as its theme

sible for overseeing the implementation of the tobacco

in 2002 in an attempt to educate people about the risks of

control strategy.

tobacco use.

In addition, securing funds from UNICEF and WHO con­
tributed to the intervention process. A tobacco control

programme requires funding, and currently the MOH does

not have adequate funds to support the programme.
4

•)

Jordan: Mass Media Campaign Combating Smoking Requires Serious Commitment and Not Just Words

Key actors in the process

Jordan's anti smoking regulation was part of a public
health law issued in 1971. Those who violate the public

Fighting tobacco use in Jordan required partnership

health law are subject to a jail sentence that does not

between the Health Ministry through the tobacco control

exceed four months, or a fine ranging from JD 25 to JD

programme, UNICEF, WHO, the steering committee and

500 or both penalties. The public health law does not

JASS. The Health Ministry's tobacco control programme

include any direct article that deals with violating the anti­

played a key role in the intervention policy. Planning activ­

tobacco regulation. In other words, there are no clearly

ities, training of employees, research and follow-up were

defined penalties for those who smoke in public places

among its main responsibilities.

and on public transport and advertise tobacco use.

UNICEF and WHO provided technical and financial assist­

Effectively, and from a technical point of view this renders

ance for the tobacco control programme and helped to

the punishment unconstitutional unless a direct article

establish an anti-smoking clinic. During 2001 and 2002,

addresses the issue of penalties related to the anti-tobacco

WHO contributed approximately USS 40,000 for anti­

regulation. Ministries in charge are also not enforcing the

smoking activities at the national and international level.

law, because a mechanism of enforcement requires coordi­

This included seminars, research and educational material

nation between various government institutions. Failure to

as well as training of staff, and participation in the inter­

enforce the legislation was not limited to this law and reg­

governmental negotiating body for the FCTC.
UNICEF contributed financial assistance of well over USS

ulation, but in fact many regulations in Jordan were aban­

doned by the executive authorities for no clear reasons.

200,000 over the past two years. It sponsored the media

The anti-smoking legislation, like many other laws in

campaign and seminars, and helped the Education Ministry

Jordan, was not put into effect due to financial and budg­

integrate a school-based educational programme in 27

etary restrictions. In this respect, the Government should

schools. It strengthened the infrastructure of JASS as well

issue clear regulations and instructions to specify the proc­

as sought to increase awareness of the existing anti-smok­

ess of enforcement. The implementation process is bound

ing regulation.

However, the intervention policy is facing an uphill chal­

lenge from tobacco companies because of their strong

financial resources and marketing capabilities. Although

tobacco advertising is banned, tobacco is still marketed
attractively in tobacco-outlet stores, through offers of cash
prizes and a variety of gifts such as T-shirts, watches and

sports bags that appeal to adolescents. Female representa­
tives also display different-coloured cigarette packages and

encourage shoppers to try cigarettes free-of-charge.
Eye-catching posters are placed on shop fronts, where

by a budget drawn up by the Minister of Finance. As such
the Health Ministry cannot enforce the law on its own, and

it does not have an annual budget earmarked for tobacco

control policy. It relies heavily on external funding from
WHO and UNICEF. In addition to these limitations, there

is no serious commitment on the part of policy-makers to

enforce existing laws, especially those concerning smokers.

The intervention's success
At this stage, it is too early to determine whether the

intervention has had any positive impact on tobacco use.

smoking is seen as a glamorous act. The amount of fines

Such policies enforced in developed countries have taken

imposed on such violations is low and they do not exceed

years to bear fruit. In addition, there are no studies avail­

JD 500. Penalties are also not strictly imposed. As such,

able on the knowledge, attitudes and practice of tobacco

tobacco companies are not deterred from attempting to
promote tobacco use.

Cross-border advertisements promoting tobacco use on
the Internet and on privately owned Arab satellite stations

also target a wide range of viewers. Lax law enforcement
of the anti-smoking regulation also constitutes another

stumbling block in the country’s efforts to fight tobacco
use.

use. Yet, raising awareness about the anti-smoking legisla­

tion through the billboard campaign raised public inquiries.
According to the tobacco control programme, adults over

20 years of age wanted to learn more about the anti­

smoking legislation. But it was not known how many calls
the programme received during the three-month cam­
paign that started in November 2001. Since the billboards
were concentrated in Amman only as a result of limited

funds, the message failed to reach the desired target
groups, namely the adult population.

5

Meanwhile, radio listeners and TV viewers who witnessed

smoking, was a successful pilot project. Feedback from

the campaign learned about the existing anti-smoking

JASS and the tobacco control programme suggested that

regulation, the dangers of passive smoking and the risks

parents, students and teachers perceived it as positive

inflicted on those consuming the various types of tobacco

intervention.

products. This campaign was also limited to one week due
to funding constraints, so that the message did not reach

the general public, as it was initially planned.

Adequate resources should be provided for anti-smok-

ing educational programmes to ensure that this project
becomes accessible in all the schools in Jordan. School­

The intervention's outcome, although undocumented,

based tobacco prevention programmes should be intro­

was modestly successful in a number of ways that are

duced in late elementary grades to prevent the onset of

worth mentioning. Two tribally dominated governorates

smoking. This project should also be incorporated in school

have announced to their communities that cigarettes are

no longer part of a traditional offering at weddings and
funerals as well as other social gatherings. A number of

private companies, and government institutions declared

themselves smoke-free and reserved a special room for
smokers. The Ministry of Education has prohibited teachers

from smoking in schools. As a result, private schools have

restricted smoking during working hours. Public schools,

where teachers once shared cigarettes with students, are

becoming tough on the practice.
Many supermarkets have placed signs displaying the juve­
nile law that restricts minors’ access to tobacco. According

to the tobacco control programme, shopkeepers often ask
buyers whom they suspect are minors for identification
before selling them tobacco products.
Yet despite these positive signs, success may have been

very limited. School students smoke outside school cam­
pus, security personnel and law enforcement officers

smoke in public places, including the airport, and despite

curricula.

The media campaign in newspapers, radio and TV, with
their broad spectrum, could have played a major role in
offsetting tobacco publicity. Adolescents are more likely to

be influenced by advertising since they are the present tar­
get group for tobacco companies. However, Jordan cannot

limit cross-border marketing on the Internet and privately
owned Arabic satellite station.

In this regard, counter-marketing efforts through media
advocacy with sufficient reach, frequency and duration

are needed to raise public awareness about the risks of

tobacco use, and to promote cessation.
Adequate funds and resources, including experienced
people are required to ensure that the campaign educates
adolescents and adults on the hazards of smoking. In addi­
tion, other counter-marketing efforts through a variety of

appealing techniques are called for instead of communi­
cating redundant themes.

no-smoking signs, minors can purchase cigarettes from

An annual budget earmarked for a tobacco control pro­

street peddlers C5).

gramme to carry out its activities is necessary. Jordan

Conclusion

to enforcing laws to fight tobacco use. Unfortunately,

The introduction of legislation restricting tobacco sales to

ing legislation is at the legislative bureau and introducing

needs to double its efforts and show serious commitment

until now, the mechanism of implementing the anti-smok­
minors and the anti-tobacco peer education project are key

legislation without enforcement is not enough to fight

steps in the country's intervention policy. Smoking among

smoking. When such issues are addressed, then it will be

minors is a growing problem in Jordan, especially since
minors comprise half of the population. These are two pri­
mary areas that require the Government's serious attention.
Enforcement of the law restricting minors' access to tobac­

co through random check-ups on retail tobacco outlet

shops and on street vendors from whom minors attempt
to purchase cigarettes as well as the imposition of penal­

ties on retailers is needed to help implement the law.
The peer education school programme, which targets
13- to 15-year-olds, the typical age when students start

possible to generalize the country’s experience.

Jordan: Mass Media Campaign Combating Smoking Requires Serious Commitment and Not Just Words

References
1.

Jordan Department of Statistics. 2002 population-based sur­

Resources
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Experts tackle religious, health issues on smoking. The Jordan

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World Health Organization, Amman office, personal inter­

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Morbidity Study, Johns Hopkins University, Ministry of

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Department of Statistics, 1996.

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Jordanian Anti-smoking Society, personal interview with
Captain Waleed Nazal.

'No smoking' regulations still being neglected, say anti-smok-

ing activists. The Jordan Times, 4 June 2002.

Multinational Steering Committee, personal interviews with

members such as Dr Bassem Hijawi.

Health of Jordan, World Health Organization and Jordan

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Jordanian National Cancer Registry, personal interview with Dr

Bassem Hijawi

view with Dr Ala'a Alawa.

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Jordan Health Ministry, Education Department, personal inter­

view with Muna Hamzeh.

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interview with Dr Hiba Ayoub.

vey

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The United Nations Children's Fund, personal interview with
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A Report on
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Islamic Republic of Iran

WHO/NMH/TFI/FTC/03.15

A Report on Smoking Advertising
and Promotion Bans in
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Ministry of Health and Medical
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Occupational and Environmental Health

Management Centre

Secretariat of the National Tobacco Control
Committee Islamic Republic of Iran

World Health Organization

World Health Organization

r
Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

WHO Regional Office for Africa (AFRO)

Cite du Djoue

Bolte postale 6

WHO Regional Office for Europe (EURO)

8, Scherfigsvej
DK-2100 Copenhagen

Brazzaville

Denmark

Congo

Telephone: +(45) 39 17 17 17

Telephone: +(1-321) 95 39 100/+242 839100
WHO Regional Office for South-East Asia (SEARO)
WHO Regional Office for the Americas / Pan
American Health Organization (AMRO/PAHO)

World Health House, Indraprastha Estate
Mahatma Gandhi Road

525, 23rd Street, N.W.

New Delhi 110002

Washington, DC 20037

India

U.S.A.

Telephone: +(91) 11 337 0804 or 11 337 8805

Telephone: +1 (202) 974-3000
WHO Regional Office for the Western Pacific
WHO Regional Office for the Eastern

(WPRO)

Mediterranean (EMRO)

P.O. Box 2932
WHO Post Office

Abdul Razzak Al Sanhouri Street, (opposite Children's
Library)
Nasr City, Cairo 11371

Egypt
Telephone: +202 670 2535

2

1000 Manila

Philippines
Telephone: (00632) 528.80.01

A Report on Smoking Advertising and Promotion Bans in The Islamic Republic of Iran

Introduction

0

ing and promotion, the Council of Ministries approved a

number of regulations, which are mentioned below:

The Islamic Republic of Iran is a country of 1 648 000
square kilometres, with a population of some 70 000 000.

Approval by the Council of Ministries

Before the Islamic revolution in 1979, the country had

A: A plan for how to decrease smoking

a national State-owned tobacco monopoly which was

(Date: 3 September 1994)

responsible for producing tobacco products for domestic
consumption as well as importing different tobacco brands

into the country. There are no data available on tobacco
product smuggling before the revolution. While the

tobacco monopoly continued following the revolution, the
importation of tobacco products ceased.

Article 4: Any activity and propaganda that results in peo­

ple being encouraged or motivated to smoke is prohibited
at all the ministries, Government organizations and insti­

tutes, Islamic revolutionary institutions, municipalities, and
departments to which the application of the law involves

mentioning the names, and at the office buildings affili­
Although there was no tobacco advertising on radio or

ated with them.

television before the revolution, advertising and promotion

of various cigarette brands was displayed on billboards

throughout the country, in the streets and on highways, in
public spaces, public transport vehicles and in movies as a
sign of prestige.

Article 6: The Ministry of Health and the Ministry of

Industries will be responsible for supervising the proper

implementation of these regulations and for codifying
appropriate circulars within the limits of the laws.

B: Regulations relating to "The ban on smoking and

Smoking was not prohibited in public areas; public trans­
port vehicles and work places and smokers smoked freely

supply of cigarettes and other tobacco products in
public places" (Date: 4 January 1997)

in all such areas. There was no legislation on the various

aspects of smoking, including production, distribution,

Article 2: To prevent youth from becoming addicted and

retail and advertising. After the revolution, a group of

to elucidate smoking's damage to health as well as the

experts, among them physicians, pharmacists, religious

financial and social harm done by smoking, the Ministry of

leaders, traders and other social groups, came together

Health, the Ministry of Culture and Islamic Guidance, the

from a religious and social health standpoint to combat

Islamic Republic of Iran Broadcasting, along with cultural

smoking and cigarette companies. They understood that

departments and municipalities will be required to pre­

smoking was highly dangerous to people's health.

vent any act and propaganda that results in people being

These actors began lobbying the country's leaders to per­

tobacco. They will be required to embark on preparing

encouraged or motivated to smoke or further consume
suade them to restrict tobacco production and smoking
in public places as well as ban tobacco advertising and
promotion. Their activities resulted in the proposal How to

regular, coordinated and appropriate cultural and propa­

ganda programmes for the public, especially youth, that
show disapproval of smoking and elucidate the harm done

gradually decrease and eliminate tobacco smoking, which

by it. These agencies are to take necessary measures to

was introduced to parliament and passed by the parlia­

ensure that this law is properly implemented.

mentary delegates in 1992 and became law. However, the

Guardian council, which is responsible for reviewing laws

Note 2. Any propaganda and activity that will result in the

passed by the parliament to ensure that they do not vio­

public being encouraged to smoke, will be prohibited.

late the Islamic Republic of Iran's constitution and religious

Article 3: The Islamic Republic of Iran Broadcasting, the

laws, rejected it on the grounds that it violated the coun­

Ministry of Cultural and Islamic Guidance, municipalities

try's constitution because certain parts of the law imposed

and the mass media must take necessary measures to

a financial burden on the Government.

ensure that smoking is not directly or indirectly encour­

Description of the intervention policy

do not smoke.

While the 1992 Guardian Council proposal was rejected, in

Advertising bans cover both direct and indirect activities,

line with the Government of the Islamic Republic of Iran’s

which promote and encourage smoking among people.

policy to prohibit any kind of tobacco product advertis­

Other policies such as prohibition of smoking in public

aged in their work, publications, films and serials, which

includes ensuring that the leading characters in their films

3

World Health Organization

Table 1
Smoking prevalence by sex and age in the Islamic Republic of Iran 1991

Total

40-69

Age (year)

15-24

Sex

Male

Smoking

N

%

N

%

N

%

N

%

N

%

N

%

N

%

N

%

Non-

3568

89.9

4982

99.3

2792

63.3

4839

97.5

2754

66.2

3802

92.3

9114

72.8

13623

96.6

207

5.2

26

0.5

622

14.2

87

1.8

356

8.6

164

4

1185

95

277

2

94

2.4

3

0.1

376

8.6

27

0.5

287

6.9

71

1.7

757

6

101

0.7

99

2.5

5

0.1

600

13.7

11

0.2

766

18.4

80

1.9

1465

11.7

96

0.7

3968

100

5016

100

4390

100

4964

100

4163

100

4117

100

12521

100

14097

100

25-39

Female

Male

Female

Male

Female

Male

Female

smoker
1-9
cig/day

10-19

cig/day
>20

cig/day

Total

Table 2
Smoking prevalence by sex and age in the Islamic Republic of Iran 1999
Age

25-39

15-24

40-69

Total

>70

(Year

Sex

Male

Female

Male

Female

Male

Smoking

N

%

N

%

N

%

N

%

N

Non-

4922

92.9

6749

99.8

3663

67.2

6481

99.1

206

3.9

4

0.1

741

13.6

41

94

1.8

5

0.1

448

8.2

77

1.5

3

0

598

5299

100

6761

100

5450

Female

Male

Female

Male

N

%

N

%

N

%

N

%

N

3377 67.7

5379

96.3

755

77.2

843

94.3

12717

76.1

19452 98.3

0.6

435

8.7

125

2.2

87

8.9

25

2.8

1469

8.8

195

1

7

0.1

396

7.9

39

0.7

48

4.9

11

1.2

986

5.9

62

0.3

11

12

0.2

779

15.6

45

0.8

88

9

15

1.7

1542

9.2

75

0.4

100

6541

100

4987

100

5588

100

978

100

894

100

16714

100

19784

100

%

Female
%

smoker
1-9 Cig/
day____
10-19
Cig/day

> 20 cig/
day____

Total

places and prohibition of purchase of tobacco products

as the Islamic Republic of Iran Broadcasting, the Ministry

by youth under 18 years of age are enforced at the same

of Cultural and Islamic Guidance, municipalities and the

time. In addition, smoking cessation clinics will offer their

mass media. The Anti-smoking National Committee of
the Ministry of Health assumed the role of observing and

consultative services to help smokers quit.
Steps toward implementation

following up on the proper implementation of these regu­

lations at the national level. There was no opposition to

Following the approval of "A plan for how to decrease

these regulations in the country since the Government had

smoking” (Date: 3 September 1994) and ”A ban on smok­

a monopoly on the tobacco industry.

ing cigarettes and other tobacco products in public places”

(Date: 4 January 1997), these regulations had to be imple­

mented by the different ministries and organizations, such

A Report on Smoking Advertising and Promotion Bans in The Islamic Republic of Iran

The intervention's success
The prohibition of smoking advertising has been a very
successful policy and was well received by the communi­
ties. Indeed, there is no direct or indirect advertising and

promotion of tobacco products and there is no tobacco

sponsorship of sports or cultural programmes throughout
the country.
Since the Islamic revolution, transnational tobacco-produc ­

ing companies have had no economic support for their
products in the Islamic Republic of Iran. The national

tobacco industry is not allowed to engage in any promo­
tional or advertising activities within the country.

Based on statistics published by the Ministry of Health and

Medical Education in 1991,14.6% of the Islamic Republic
of Iran’s population were smokers and in 1999 this rate

decreased to 11.7%. Tables 1 and 2 show smoking
prevalence by age and sex in the Islamic Republic of Iran
between 1991 and 1999. As these tables demonstrate,

smoking prevalence has decreased among males from
27.2% in 1991 to 24% in 1999 and from 3.4% to 1.5%

among females in the same period.

Conclusion
As mentioned earlier, since the Islamic revolution no for­
eign industries have been permitted activities within the

tobacco industry and national media has not been permit­
ted to promote and advertise tobacco products. Therefore,
it is not possible to estimate the financial loss incurred by

the media and other enterprises.
A comprehensive ban on tobacco product advertising

was a successful policy thanks to the collaboration of all
the organizations involved in the implementation of the

Council of Ministries' decision.

Indeed, there was no opposition to this policy because
international corporations do not have any activities

within the country and the tobacco industry is entirely run
by the Government of the Islamic Republic of Iran. The

result of all these policies has been a decline in smoking
prevalence from 1991 to 1999. In the end, the Ministry
of Health strongly opposed privatization of the tobacco

industry because it facilitates the entrance of transnational
companies into the country. These companies would begin
opposing the restrictions on advertisement of their prod­
ucts, which would eventually increase tobacco use in the

Islamic Republic of Iran.

Labelling and Packaging
(including Health

p1''’15

Warnings)

European Community Directive on
Packaging and Labelling of Tobacco Products

European Community Directive on
packaging and labelling of tobacco products
Luc Joossens
WHO Consultant

ii? World Health Organization

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

WHO Regional Office for Africa (AFRO)

WHO Regional Office for Europe (EURO)

Cite du Djoue

8, Scherfigsvej

Boite postale 6

DK-2100 Copenhagen

Brazzaville

Denmark

Congo
Telephone: +(1-321) 95 39 100/+242 839100

Telephone: +(45) 39 17 17 17

WHO Regional Office for South-East Asia (SEARO)

WHO Regional Office for the Americas I Pan

American Health Organization (AMRO/PAHO)

World Health House, Indraprastha Estate

Mahatma Gandhi Road
525, 23rd Street, N.W.

New Delhi 110002

Washington, DC 20037

India

U.S.A.
Telephone: +1 (202) 974-3000

Telephone: +(91) 11 337 0804 or 11 337 8805

WHO Regional Office for the Western Pacific

WHO Regional Office for the Eastern

(WPRO)

Mediterranean (EMRO)
P.O. Box 2932

WHO Post Office

Abdul Razzak Al Sanhouri Street, (opposite Children's
Library)

Nasr City, Cairo 11371

Egypt
Telephone: +202 670 2535

1000 Manila
Philippines

Telephone: (00632) 528.80.01

European Community Directive on packaging and labelling of tobacco products

Directive 2001/37/EC of 5 June 2001 concerning the
manufacture, presentation and sale of tobacco products

the tobacco industry's strategy. Ridiculing the health conse­

was published in the Official Journal of the European

the argument that the proposed Directive would be violat­

Communities on 18 July 2001. It was introduced in

ing the German constitution. The tobacco industry's strate­

the national legislation of the 15 European Union (EU)

gy failed into the short term since the German Government

Member States on 30 September 2002. The Directive

quences was one of their tactics. Another was to advance

supported the first Labelling Directive (89/622) in 1989®.

contains provisions on maximum yields, warning labels,

In the long term, however, the tobacco industry strategy

reporting requirements, misleading descriptors, traceability,

was successful because the German Government would

monitoring and review. This paper discusses the provisions

eventually become the industry's strongest ally in Europe.

on packaging and labelling and assesses their impact.

The European labelling legislation finally resulted in two leg­
islative measures: Directive 89/622 of 13 November 1989

and Directive 92/41 of 15 May 1992. This legislation pushed

History of the packaging and labelling of
tobacco products in the European Union

Member States, many of whom had had little or no legisla­

tion on labelling, to adopt a system of warnings and product
information that is relatively satisfactory from a public health

The Treaty of Rome, which established the Community

point of view, in particular, the introduction of rotating

in 1957, did not contain a specific article that gave the

warnings. However, despite the amendments adopted in

community competence in public health. In 1985, two

1992, which reinforced, in particular, the labelling of tobacco

political leaders—President Mitterrand of France and Prime

products other than cigarettes, the European legislation had

Minister Craxi of Italy—felt strongly that the Community

several weaknesses that needed to be addressed. The two

should become more involved in public health. At their

weak points of the Directives' labelling requirements were

bi-annual meeting in Milan in 1985, the heads of state

the warnings' small size and lack of visibility.

and of Governments of the Member States of the
European Community called on the Commission to launch

a European Programme against Cancer®. A high-level
cancer-expert committee was established to advise the
European Commission. At its meeting in February 1986

a comprehensive set of measures to combat cancer was
formulated. An action plan was elaborated upon with the

aim of reducing the number of deaths by 15% in 2000.
Fourteen of the proposed actions of the "Europe against

Cancer" programme were related to tobacco control. One

of proposed measures was to introduce European tobacco
labelling legislation.

The European Community legislative process is long and

The small size of the warnings

According to the Directive 89/622, the general warning
and the specific warnings must cover at least 4% of each

of the large surfaces of the cigarette pack, excluding the

indication of the authority that is author of the warnings.
Warnings should ideally be printed in sufficiently large
characters so as to be easily read by the consumer. This

means that a large area of the pack needs to be reserved

for this purpose. In this context, the 4% of the pack
planned in the Directive seemed derisory. This was con­

firmed by research inside and outside the EU. The follow­
ing two findings demonstrate this point:

complex and cannot be described in detail in this paper. The

- Qualitative research and quantitative research

lobbying activities around these directives were described

among 2 000 adults in the United Kingdom in

by Michel Richonnier, who was in charge of the Programme

November 1990 to test the new EU health warnings

"Europe against Cancer" during the period 1996-2001 «>.

concluded that:

The tobacco industry was strongly opposed to new leg­
islative measures and was omnipresent at every level of
European decision-making. The tobacco industry put heavy

pressure on governments to oppose the directive.

the impact of the new pack warnings is likely to

be marginal whatever the nature of the message,
because of their comparatively small size. At 4% of

the pack face, they are difficult for many to read,

At the Council of Ministers on 16 May 1989, the British

and comparatively easy to ignore. There is a tenden­

Minister of Health voted against the directive since

cy to interpret the smallness of the warnings as evi­

the Government of the United Kingdom felt that the

dence of government complicity. More worryingly,

Community had no health competence to introduce such

there seems to be a tendency to equate the size of

legislation. The German Government was another target in

the warning with the magnitude of the risk3

World Health Organization

- Despite the fact that EU legislation on labelling came

Member State where the product is placed on the

into force on 1 January 1992 and contained an obli­

market, so that at least 10% of the corresponding

gation to have warnings on the front and the back

surface is covered (12% for two official languages

of the packs, research in 1997 among 1 OCX) people

and to 15% for three official languages).

in the United Kingdom showed that:
only 29% of the smokers, 28% of the ex-smokers

- Warning labels should cover 30% of the front of the
pack (32% for two languages and 35% for three

and 30% of the non-smokers were able to say that

languages) and 40% of the back of the pack (45%

the warning was printed on the front of the pack <4>.

for two languages and 50% for three languages).

The lack of visibility

- Warning texts should contain a general warning
on the front—either "Smoking kills" (or "can kill",

Another vulnerable point of the Directive was the require­

depending upon transposition) or "Smoking seriously

ment that warnings be printed on a contrasting back­

harms you and those around you" to be rotated on

ground. In the Oxford English dictionary "contrasting"

a regular basis; additional warnings on the back—a

is defined as "a juxtaposition or comparison showing

list of about 12 different texts, also to be alternated

striking differences". According to a report undertaken by
the European Bureau for Action on Smoking Prevention
(BASP) at the request of the Commission of the European

Communities, the contrasting background was a major
problem. In August 1993, a survey of the top five ciga­

rette brands in the EU countries, which covered some 60%
of the European cigarette market, indicated that the colour

gold was used for the lettering of the warnings on 68% of
the packs. The use of gold lettering was considered by the
authors to be against the spirit of the EU Directive because

as a reflective colour it offered only a minimal contrast.
A number of other colour combinations were also felt to
have been chosen deliberately with a view to minimizing

the warning's visibility (grey on white, blue on darker blue,

on a regular basis.

- The text of warnings and yield indications shall

be printed in black Helvetica bold type on a white
background; in lower case type, except for the first
letter of the message and where required by gram­

mar usage; centred in the area in which the text is
required to be printed, parallel to the top edge of
the packet; surrounded by a black border not less

than 3 mm and not more than 4 mm in width, which
in no way interferes with the text of the warning or

information given; in the official language or lan­
guages of the Member State where the product is

placed on the market.

etc.) In certain cases, the choice of colour was felt to so

The Commission prepared rules for the use of colour pho­

severely undermine the intention of EU legislation as to be

tos (e.g. as recently introduced in Canada), graphics, etc.

contravening the Directive <5>.

on 5 September 2003. Member States that wish to author­

The new labelling provisions of the Directive

do so, but only within the context of the agreed rules. The

2001/37/EC

implementation of the use of colour photographs or other

ize the use of pictures, etc. would then still be entitled to

The main criticism of the previous legislation on label­
ling was the warning’s lack of visibility as a result of its

small size and the colour of the lettering, which failed to
adequately contrast with the background colour of the

illustrations as health warnings shall apply as of 1 October
2004 at the earliest (Commission Decision of 5 September

2003).
- Mechanisms were introduced to ensure that the

pack. New EU legislation (Directive 2001/37/EC) would

implementation of the Directive is properly monitored

increase the size of warnings (from 4% to 30% and 40%)

and that the provisions of the Directive are kept

and stipulate in very precise terms in which colours the

up-to-date in terms of scientific developments. The

warnings should be printed (black on white, surrounded
by a black border).

Commission shall be assisted by a committee of rep­

resentatives of the Member States to adapt to scien­

tific and technical progress: the maximum yield meas­
The main provisions on packaging and labelling in the

urement methods and the definitions relating thereto;

Directive 2001/37/EC are the following:

the health warnings and the frequency of rotation of

- The tar, nicotine and carbon monoxide yields of cig­

arettes shall be printed on one side of the cigarette

4

packet in the official language or languages of the

the health warning and the marking for identification
and tracing purposes of tobacco products.

European Community Directive on packaging and labelling of tobacco products

- No later than 31 December 2004, the Commission

shall submit a report on the application of this

that the black border should be additional to the warning,
which resulted in a legal challenge by Philip Morris on the

Directive and shall pay special attention, among

interpretation of this article of the Directive in Sweden.

other things, to:

The tobacco industry lost this case. On 10 October 2002,

• improvements in health warnings, in terms of size,
position and wording,

• new scientific and technical information regard­
ing labelling and the printing on cigarette packets
of photographs or other illustrations to depict and

explain the health consequences of smoking,

0

the Swedish Cabinet of Government Ministers decided on

the case and rejected the arguments of Philip Morris. The
black border interpretation has not led to legal challenges

in other countries. In Belgium, for instance, provisions
regarding the black border are laid down in Article 3 of the

Royal Decree of 29 May 2002. In the comments to this
new Article, it is clearly laid down that the texts in ques­

• methodologies for more realistically assessing and
regulating toxic exposure and harm,

• development of standardised testing methods to

tion shall be surrounded—in addition—by a black border.

It is also being stated that the EU Commission officially has
confirmed that the Directive thereby has been correctly

measure the yields of constituents in cigarette smoke

implemented in Belgian legislation. Moreover, the Belgian

other than tar, nicotine and carbon monoxide.

constitutional court (Conseil d'Etat, legal advice of 19
February 2002) agreed with this interpretation, acknowl­

Implementation of the Directive 2001/37/EC

Directive 2001/37/EC of 5 June 2001 concerning the

edging that only the European Court Justice will have a
final say on this interpretation. Considering that Belgium

manufacture, presentation and sale of tobacco products

has three official languages, which increases the size of

had to be introduced in the national legislation of the

warnings from 30% to 35% and from 40% to 50%, add­

15 EU Member States by 30 September 2002. Products

ing the black border in addition to the warnings, means

that did not comply with the warning provisions of

that in that country the size of the warnings will be 46%

the Directive could continue to be marketed until 30

of the front and 62% of the back of the cigarette packs.

September 2003. The ten European accession coun­

The new EU warnings have been warmly welcomed by

tries, which will join the European Union in May 2004,

health organizations. The only major criticism of the new

also have to introduce the Directive into their legislation

legislation is the printing of the tar, nicotine and carbon

according to a time table agreed upon with the EU.

monoxide yields of cigarettes on the packs, since the tar

The impact of labeling regulation cannot yet be measured

and nicotine yields are based on ISO measurements and do

since the new warnings have not been available in most EU

not provide meaningful information for consumers. One of

countries until recently. Cigarette packs with the new, bigger

the recommendations of the WHO conference Advancing

health warnings have only been on sale in the Netherlands

knowledge on regulating tobacco products, was to remove

since 1 May 2002 (Decree of 21 January 2002).

these yields from the packs <®. During the discussions on

The Directive was challenged in the European Court of

that it would be wrong not to provide the consumers with

the directive, some representatives of health ministries felt
Justice by British American Tobacco, Imperial Tobacco and

any information on the yields on the packs.

Japan Tobacco International. The Advocate General of

the European Court of Justice published its Opinion on 10

September 2002 on the legal challenges to the Tobacco
Products Directive. He believes that the Directive is valid,

Impact of the labeling provisions

and recommends that the Court should rule accordingly.

In most EU countries the new health warnings have not

On 10 December 2002, the Court decided to uphold the

been visible until recently on cigarette packs. Products that

validity of the Directive. (Case 491/01). This decision can

be considered as a major setback for the tobacco industry.
There has been discussion as to whether the three-mil­

limetre black border surrounding the warnings should

be additional to the health warning area or part of it. In
Sweden the National Institute of Public Health decided

do not comply with the warning provisions of the Directive

could continue to be marketed until 30 September 2003.

The exception is the Netherlands, where tobacco products
with the new warnings have been on the market since

May 2002. On 26 November 2002, the Dutch organiza­
tion Defacto presented the results of two Dutch studies

on the effects of the new health warnings on the cigarette

5

World Health Organization

packages. One study was conducted among a representa­

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Smoke-free
Policies

WHO/NMH/TFI/FTC/04.06

Report on National Policies on Tobacco
Smoke-free Environments in Chile

Report on national policies on tobacco
smoke-free environments in Chile
Dr Sergio Bello
National Chest Institute
Tobacco Smoke Free Environments Programme

(TSFEP)
Ministry of Health, Chile

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices
for their contribution to this project.

WHO Regional Office for Africa (AFRO)

WHO Regional Office for Europe (EURO)

Cite du Djoue

8, Scherfigsvej

Bolte postale 6

DK-2100 Copenhagen

Brazzaville

Denmark

Congo

Telephone: +(45) 39 17 17 17

Telephone: +(1-321) 95 39 100/+242 839100

WHO Regional Office for South-East Asia (SEARO)
WHO Regional Office for the Americas / Pan

American Health Organization (AMRO/PAHO)

World Health House, Indraprastha Estate
Mahatma Gandhi Road

525, 23rd Street, N.W.

New Delhi 110002

Washington, DC 20037

India

U.S.A.

Telephone: +(91) 11 337 0804 or 11 337 8805

Telephone: +1 (202) 974-3000
WHO Regional Office for the Western Pacific
WHO Regional Office for the Eastern

(WPRO)

Mediterranean (EMRO)
P.O. Box 2932

WHO Post Office

Abdul Razzak Al Sanhouri Street, (opposite Children's
Library)
Nasr City, Cairo 11371

Egypt
Telephone: +202 670 2535

1000 Manila
Philippines

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Report on national policies on tobacco smoke-free environments in Chile

90.6% of those who had given up smoking had done so

Introduction

six months or more ago.
Prevalence of smoking in Chile

As regards exposure to environmental tobacco smoke at

The findings of the surveys carried out by the National

the workplace, smoking was completely prohibited in more

Drug Control Council (CONACE), which have been con­

than one-third of workplaces and restricted in the other

ducted every two years from 1994 to 2000, are the most
reliable source of data on drug consumption in Chile.

two-thirds, although the figures reported by men and
women differed. Smoking in the home was restricted by

family agreement in 48.5% of homes (Table 2).

Table 1 shows levels of prevalence in the years in which

Table 2. Perception of smoking prohibition

the survey was conducted.

indoors, by sex. Quality of life survey 2000
Men (%)

Women (%)

Total

Table 1. Prevalence of smoking (last month)

Workplace

29.1

43.8

34.8

Home

46.5

50.1

48.5

among Chile's general population

Year

Men

Women

Total

1994

45.4

36.3

40.5

Data obtained by CONACE in association with the

1996

45.3

36.2

40.4

Ministry of Education and the Ministry of Health, which

1998

47.2

35.5

40.9

carried out surveys in 1995, 1997, 1999 and 2001 among

2000

47.7

39.5

43.2

12- to 18-year-old schoolchildren found that on average
the age at which they smoked their first cigarette was
13, with a trend towards smoking the first cigarette at an

These data show the rising trend in tobacco use between
1994 and 2000, with a higher increase among women;

this is even more striking if we compare these data with
those from the survey carried out by Joly in 1971, which
found prevalence among women to be approximately

20%. Prevalence has thus doubled in 30 years, and the
gap between men and women has narrowed.

increasingly low age.

The 2001 survey showed that annual prevalence (tobacco

consumption in the year prior to the survey) had risen by
two points, a rise attributable to the 4.4 point increase
in smoking among adolescent girls. However, last-month

consumption declined between 1999 and 2001, as is
shown in Table 3.

As for prevalence in the last month, broken down by

socioeconomic status, it is noteworthy that people of
lower socioeconomic status smoke most; prevalence

Table 3. Last-year and last-month tobacco

among them is 44.1 %, while among people belonging to

consumption:

the higher strata it is 41.7%.

12- to 18-year-old schoolchildren in Chile

Boys

The first National Quality of Life Survey (2000)’ yielded

results that are consistent with those of CONACE.

Last
year

Prevalence in the last month was 40%, and was higher

among men (44.1 %) than among women (36.6%) and
among urban dwellers (40.9%) than among the rural

population (32.6%). Significantly, 32.5% of smokers said
they intended to give up smoking the following month,
evidence of willingness to change behaviour. A total of

National Quality of Life Survey 2000. Dept, of
Epidemiology and Dept, of Health Promotion. Ministry of
Health, Chile.

Last
month

Girls

Last
year

Last
month

Total

Last
year

Last
month

1995

54.3

33.3

58.3

36.3

56.3

34.8

1997

53.5

44.4

59.7

48.2

56.6

46.4

1999

51.4

41.1

55.8

44.7

53.7

43.6

2001

51.2

38.7

60.2

45.0

55.7

41.8

World Health Organization

Mortality from tobacco in Chile

The Ministry of Health's Department of Epidemiology has

indicated that according to mortality statistics for 1999,

16.9% of total mortality in that year was attributable to

tobacco (13 888 deaths); 8888 (64%) were from cardio­

Places in which smoking is partially banned
Smoking is not permissible, except in specially designated

areas:

- hospitals, clinics, surgeries and health posts;
- theatres and cinemas.

vascular disease, 2917 (21%) from various forms of cancer
and 2083 (15%) from respiratory illness.

Description of the policy of action
One of the priorities of the National Health Promotion
Plan for the six-year period 2000-2006 is to «check the

surge in risk factors for health». One of the most impor­

Government offices, including municipal offices

Two categories are distinguished:
- premises on which services are provided to the pub­
lic: smoking is completely prohibited;

- premises on which services are not provided to the
public: smoking is neither prohibited nor restricted;

tant of these is smoking, on account of its numerous

harmful effects on health.

Restaurants, bars, hotels and other establishments

The shift in the approach to smoking as a social phenom­

It is left to the establishment to set aside smoking and

enon is one of the strategies to have proved most effective

non-smoking areas. Any such divisions must be sign­

in controlling this global epidemic. The strategy's aim is to

posted.

portray smoking as socially unacceptable behaviour, which
is a private rather than a public habit.

Despite the law, tobacco control has not improved since its

adoption, hence the need for programmes to encourage

As part of this strategy, in early 2001 the Ministry of

and make possible its implementation and to complement

Health (MINSAL) introduced its «Tobacco-smoke-free

it. The Tobacco-smoke-free environments programme con­

environments)* programme (TSFEP) as a means of encour­

tributes to this objective through participation, dialogue

aging this change in social behaviour. The programme

and agreement among all the members of a given institu­

was first implemented in the health sector and efforts are

tion, both smokers and non-smokers.

under way to introduce it into the education sector and
other areas, both public and private, and especially those
participating in the National Health Promotion Council

Vida Chile.

Objectives and strategies

The aim of TSFEP is to initiate a process leading to the
restriction of smoking on the premises of a firm, organiza­

The legal basis for the programme is Act N° 19 419

tion or institution, whether in the public or private sector.

of 9 October 1995, which relates to smoking issues.

This is achieved by reaching a consensus among all the

Significantly, article 7 of the Act lays down absolute or

institution's members. At the same time, the population is

partial prohibitions on smoking in different premises in the

encouraged to agree not to smoke in the home.

following terms:

The programme has the following objectives:

Places in which smoking is completely banned

- To help improve the overall quality of life of the

Smoking is never permissible in:

- public or collective means of transport;
- school classrooms;

- lifts;
- place in which explosives, inflammable materials,

medicaments or food are manufactured, processed,

stored or handled.

population, of workers and civil servants working
indoors by protecting them from environmental

tobacco smoke and by protecting non-smokers.
- To encourage changes in the image of smoking in
society, so that from being an acceptable habit it

becomes an unacceptable one.

Strategies

The strategies required to achieve these objectives are
described below.

Report on national policies on tobacco smoke-free environments in Chile

7. Publicity

specified on the invitations and on the premises on

A range of information, publicity and social communica-

which the event is held. It is suggested that relevant

tion actions will be used to inform and educate the popu­
lation about the programme and the reasons for it.

2.

Education

The programme undertakes educational activities targeting

documents and advertising mention this policy.

In parallel to the introduction of TSFEP, the Ministry of

Health has encouraged other tobacco-control activities in

Chile, of which the following are noteworthy:

different population groups (schoolchildren, health-service

- A number of Chilean primary health care services

users, workers, families, social organizations and citizens).

have begun to provide counselling on giving up

At the same time, human resources educational and train­

ing activities are carried out.

3.

Social involvement

The decision to establish a tobacco-smoke-free environ­

ment requires the active agreement of the members of the
organization concerned. At the same time, mechanisms for

ensuring effective social control of the measures adopted

need to be set up.

4.

Research

smoking.

- Communication campaigns:
• targeting health workers, in conjunction with the

implementation of TSFEP
• targeting children in the 5th and 6th grades of basic
education in all Chile's State-subsidized schools,

in association with the Ministry of Education
(MINEDUC).

• The Quit and Win competition, an international ini­

Research is carried out to identify the prevalence of and

tiative that Chile joined in 1998, and that has also

attitudes towards smoking among civil servants, workers

been held in 2000 and 2002. The competition has

and members of the institutions or firms taking part in the

proven very popular with the population, and in the

programme.

three years in which it has been held, it attracted

5.

Accreditation and certification of tobacco-smoke-free

12

000, 14 000 and 17 000 participants respectively.

environments

Those institutions and firms that successfully establish
tobacco-smoke-free environments will receive accredita­
tion and certification from the Ministry of Health. The

Hi Phases of implementation
- Forming the task force

Ministry will draw up and periodically issue a directory of
firms, organizations or institutions certified as providing
tobacco-smoke-free environments.

The first assignment undertaken by the Ministry of Health,
in December 2000, was to form a task force of profes­

sionals with broad experience in tobacco control. The task
6.

Internal regulations

The following proposals are made, although each institu­

tion is free to adapt them to its own circumstances:

force set about formulating TSFEP and carrying out a situ­
ation analysis in health facilities that were already free of
tobacco smoke.

- No form of tobacco consumption is permitted within
the building, the surrounding area and its entrances

and exits at any time of day.
- Signs will be put up to inform people that they are in
a tobacco-smoke-free environment and that smok­

This work resulted in a document setting out the techni­

cal guidelines needed by health teams to implement and
develop the programme. In 2002, on the basis of these
technical guidelines, TSFEP was approved as an official

MINSAL programme.

ing is prohibited.

- The decision as to whether to establish a smoking

- Management commitments

area will be taken at the local level. The area shall be

In January 2001, the programme was included among the

located on premises on which no one is required to

management commitments made by health services to
the Ministry of Health; this gave strong encouragement to

remain or to pass through for their work.

- All academic, social, commemorative or other events

its implementation as it is included in the health services

held on the premises of the establishment shall be

annual grading exercise. In 2002, TSFEP targets were also

declared «Tobacco-smoke-free events®; this shall be

included as management commitments.

- Training

World Health Organization

A two-day national training workshop was held in April
2001 for managers of health teams in health services
throughout Chile who are responsible for implementing

and running TSFEP in all Chile's regions.

The existence of a network of experienced health promot­
ers made it possible to incorporate rapidly the manage­

ment of TSFEP into the health services at the regional and
local levels.

The basic criteria for accreditation are:
- performance of specific activities: smoking surveys,

designation of the smoking area and signposting;
- presentation of formal documents: a record making
the policy official;

- public information activities: registers of press releas­

es, internal memos, etc.
Once an institution, establishment or firm has received

A summary is given below of the technical guidelines of

accreditation, it will be certified by the Ministry of Health,

TSFEP for application at the local level, together with its

which will officially issue it with a certificate.

methodology and accreditation system.

Accreditation is valid for two years, and may be renewed

1.

TSFEP methodology at the local level

The methodology breaks down into seven basic stages,

by the health authority once it has ascertained that the
criteria are satisfied.

which may be implemented gradually or in accordance

A directory listing all the institutions that have been

with the plans adopted by the local teams.

accredited and certified as TSFE is available for distribution;

The stages in the establishment of a tobacco-smoke-free
environment are as follows:

the directory will be widely distributed and will encourage

more participants to join the Programme.

Stage 1. Formation of the team, formulation of the

plan and awareness-raising
Stage 2. Survey application and analysis
Stage 3. Education and communication

Results
Quantitative achievements

Stage 4. Changes to the physical environment
By 30 August 2002, a total of 502 establishments had

Stage 5. Official declaration

Stage 6. Communication and publicity among the

community
Stage 7. Keeping the goal in sight

been accredited as TSFE; 425 of them were in the health
sector, 57 in the education sector, 11 in the local govern­
ment sector and 9 in the private sector.

As of this year, an effort is being made in the education

It is estimated that it may take approximately five months

sector through the Schools that Promote Health strategy.

to establish a tobacco-smoke-free environment in a par­

The management commitment made to the health sector

ticular workplace.

is to declare 30% of schools as tobacco-smoke-free areas.

The target for the current year is over 200 schools; we are
2.

Accreditation and certification

confident that this goal will be more than achieved.

Accreditation by the health authorities of premises as

A major effort has also been begun with several institu­

offering a tobacco-smoke-free environment is part of the

tions belonging to the VIDA CHILE network (National

regulatory role of the Ministry of Health.

Health Promotion Council).

Accreditation is awarded after the competent authorities

- Carabineros de Chile: the institution's hospital sub­

have ascertained that the suggested activities have been

mitted itself to the process and was accredited as a

carried out and after verifying the information provided to

TSFE; it was certified as such in June 2002, in the

and the impact on users and the community.

Accreditation is the responsibility of SEREMIS (Regional

Ministerial Secretariats) and of Chile's health services; the

presence of the leading authorities of the institution
and of MINSAL.
- The National School Assistance and Grants Board

health services are responsible for health facilities and

(JUNAEB), the National Sports Institute, the National

SEREMIS for other sectors.

Customs Administration, the University of Chile's

Institute of Nutrition and Food Technology (INTA)

Report on national policies on tobacco smoke-free environments in Chile

and the Catholic University of Chile, through its
healthy university strategy, have begun the TSFE

tral Ministry of Health. Training for health teams was also

provided by the TSFE programme's central team through a

accreditation process and are each at a different stage

national workshop held in early 2001, and through subse­

in the process. We are confident that they will receive

quent support in the form of supervisory visits and direct

accreditation and official certification this year.

communication via e-mail or the phone.

Degree of acceptance of the policy's impact

For the health sector, the direct per-capita cost of the TSFE

programme was approximately 800 pesos (USS 1.1).
The policy has been well received. This was shown by the

diagnostic survey in which people were asked their opin­
ion about smoking restrictions in the workplace; out of a

total of 20 848 persons surveyed countrywide, the level of

Conclusions

approval was 89.5%. According to those responsible for
promoting the policy in Chile, subsequent acceptance has

Lessons for decision-makers

been quite satisfactory.

In our opinion, the following factors contributed to the

Impact on non-smokers

satisfactory implementation of the TSFE programme:

- the reliance of TSFE on a national health promotion
Those who benefit most from this kind of policy are

policy, with a country plan and goals, which had

undoubtedly non-smokers; tobacco smoke is eliminated

already been under way for four years;

from the workplace and they are able to breathe
better-quality air. In addition, the working environment is
improved thanks to the existence of a consensus among

all the workplace's employees, which makes it possible to

resolve conflicts between smokers and non-smokers.
Documentation on the policy

For the moment, we have the data from the baseline

survey carried out when the policy was introduced in the
health sector. The study, which was carried out among

20 848 health workers throughout Chile, has provided
the programme with a firm foundation by enabling us to
determine the prevalence of smoking in each establish­

ment, together with attitudes towards smoking, both in

the home and in the workplace. It is worth mentioning

that 89.5% of those interviewed supported the restriction
on smoking. It is intended to repeat the survey in each

- the programme's design and features (technical,
political and strategic) were adapted to the Chilean

situation and relied on participative and decentral­
ized management suited to the national cultural con­

text;

- its association with an incentives system; manage­

ment commitments subject to evaluation and grad­
ing by the health services. Certification by Chile's

supreme health authority (the Ministry of Health)
served the same purpose;

- a competent and recognized management team with

technical and political support;
- the existence of real goals attainable within the time
frame;

- the availability of sufficient funds to implement the
programme.

establishment two years after the introduction of TSFE in

order to obtain objective information on developments in

The key moments in the intervention

premises on which the policy has been introduced.

At the national level, the crucial phase was the imple­
mentation of the programme, together with planning and

drafting of documents.

Other results of the programme
At the local or establishment level, the diagnostic survey

The cost to employers of implementing the programme

and awareness raising among employees, on which the

has been very low. The only expense they have had to

future development of the programme depended, were

bear has been to adapt some premises as smoking areas

for those who wish to smoke.

The other costs, both for the advertising campaign and
educational material for employees, were met by the cen­

crucial.
At every level, support from the relevant authorities has

proven vital for the programme.

0

World Health Organization

Strengths

The incentives: the management commitments and certi­

fication, which represented a meaningful ritual for institu­
tions or establishments;

Resources that might have improved the

intervention, had they been available
So far, the programme has made do with one full-time

and two part-time employees. Fresh and increased human
resources would make it possible simultaneously to address

other spheres of work, such as other workplaces, especially
in the private sector, public spaces such as airports, road
and sea transport terminals and restaurants, and to extend

coverage in important areas such as municipalities.

Requirements in order to generalize the

experience
We believe that it is perfectly possible to generalize the

experience, provided it is adapted to local circumstances. It

is an easily adaptable model, as the basic tools are simple

and may be used after basic training.
It involves little expense and a cost-effectiveness evalua­

tion is easily carried out.

8

Advertising and
Promotion
Bans

WHO/NMH/TFI/FTC/04.05

pH' I3>-

Country Report on Tobacco Advertising
and Promotion Bans-Croatia

Country report on advertising
and promotion bans - Croatia
Dr Vlasta Hrabak-Zerbajic
Epidemiology of Chronic Diseases

Croatian Institute of Public Health

World Health Organization

The ESPAD study, conducted in Croatia in 1995, was

Introduction

done again in 1999, with data collected between March

and April of that year. The sample consisted of randomly

For centuries tobacco has been grown and consumed in
Croatia. In the last century the habit of cigarette smoking

selected school classes with the highest proportion of stu­

was highly prevalent and socially accepted. People smoked

dents born in 1983. The results showed that 70% of boys

not only at home, individually or at family gatherings and

and 69% of girls in Croatia in 1999 had experimented

with cigarettes at least once, compared with 71 % of boys

celebrations but also in pubs and restaurants, at work,

meetings, and on social occasions or at media events.
Smoking was considered a sign of adulthood, as illustrated

and 67% of girls four years earlier. In 1995, 25% of boys
and 19% of girls admitted they were daily smokers, while

by the popular saying, «l am older, so I can send you to

in 1999 the corresponding percentage for boys was 30%

get me a pack of cigarettes».

and for girls 25%. Whereas 45% of male and 34% of

female respondents said they had begun experimenting

The results of the first major survey on smoking preva­

with cigarettes before their 13th birthday, 14% of male

lence in Croatia at the beginning of the 1970s, covering a

representative sample of households, showed that 57.6%

and 8% of female respondents said that by the age of 13

they had begun smoking on a daily basis (3).

of the males and 9.9% of the females between the ages

With regards to the health consequences of smok­

of 20 and 64 were smokers (1). According to the basic

indicators for the Health Promotion subproject within the

ing, it should be underscored that the two leading

First Croatian Health Project in 1997, 34.1% of Croatia’s

causes of death in Croatia are closely related to smoking.

males and 26.6% of females between the ages of 18 and

Cardiovascular diseases, with a 53.6% share in Croatia's

65 were daily smokers. The males were «heavier» smokers

mortality total in 2001, ranked first. Next in rank was

than females. Of the male smokers 40% reported smok­

neoplasms, with 23.8%, while diseases of the respiratory

ing more than 20 cigarettes a day, outnumbering the 12.5

system, with 4.1 %, were fifth (4). Using R Peto's method­

% of female smokers who had the same habit (2). The

ology presented in the World Health Organization's 1997

respondents claimed they started smoking between the

publication Tobacco or Health: A Global Status Report,

ages of 16 and 20, in contrast with the results of the inter­

Croatia's smoking-related deaths for 2001 were estimated

national study European School Survey Project on Alcohol

at 8400 (17% of all deaths), i.e. 25% of all male and 9%

and Other Drugs (ESPAD), showing the current shift

of all female deaths (Table 2). In the WHO Regional Office

towards younger age groups in starting the habit (Table 1).

for Europe, Health for All database , the standardized

Table 1. Prevalence of daily smokers in Croatia

mortality rate (SDR) for selected smoking-related causes of

death for Croatia in 2001 was 390.2/100 000.
Year of

Age (years) study population

% smokers among men

1970

20-64

57.6

9.9

1997

18-65

34.1

26.6

1995

16

25

19

1999

16

30

25

study

2

% smokers among women

Country report on advertising and promotion bans - Croatia

Description of policy interventions______

Use; (iv) Smoking Prevention Measures; (v) Surveillance;

(vi) Penal Provisions; and (vii) Transitional and Concluding
Until 1999 there were three pieces of legislation governing

Provisions.

the control of tobacco:
In the third section, Articles 9 and 10 refer to advertising.

- the Tobacco Act, which regulated the planting of

tobacco and the manufacture of tobacco products;
- individual articles of the Work Safety Act, which
forbid smoking in any room within the workplace
or closed area where meetings and gatherings take

place, but allowing firms or organizations, through
internal regulations, to permit smoking in certain

designated smoking rooms as long as this did not

infringe upon the right of non-smokers or pose a fire
hazard ;

- individual articles of the Food and Object of

Common Use Health Safety Regulation Act, which

Article 9 states:
There is a ban on advertising tobacco products through the

following means:
- mass media; and
- any type of advertising in public areas, transportation facili­
ties, means of transport; in books, reviews, calendars, on
clothing articles, stickers, posters and in leaflets, if these

stickers, posters and leaflets have been separated from the

original packaging of tobacco and tobacco products.

Considered as advertising in the sense of Paragraph 1 of
this Article are all types of either direct or indirect adver­
tising, including by show of logotypes and other marks

banned direct advertising of tobacco and alcohol

to signify tobacco and tobacco products and placed on

beverages in public places, and the display of adver­

objects that are not defined as tobacco products by this

tisements for these products in public places, on

Act. Tobacco and tobacco product handouts for advertising

buildings and in the media. It also prohibited adver­

purposes also belong to this category.

tising tobacco and alcoholic beverages in books,

Also prohibited is the advertising of products which,

reviews or similar publications or exhibiting stickers,

according to this Act, are not tobacco products but which

posters and leaflets separately from the cigarette

directly stimulate the consumption of tobacco and tobacco

packaging itself. This provision did not apply to tech­

products by their appearance and designed use.

nical publications intended for manufacturers and

The provision of Paragraph 1 of this Article does not relate

sales people or to consumer information about the

to technical books, reviews and other professional publica­

properties of tobacco manufacture in the facilities

tions describing the properties of tobacco and tobacco prod­

where such products are sold. The same act regu­

ucts, provided that these publications are intended exclu­

lated the requirement of having health warnings on
cigarette packages.

sively either for manufacturers or sellers of these products.

The provision of Paragraph 1 of this Article does not refer
to informing the consumers about the properties of tobac­

Following these regulations, the Croatian tobacco industry

co, respectively tobacco products, within the facilities in

simply changed its advertising strategy, switching from

which these are marketed. [Note: This exception was made

direct to indirect advertising. Cigarettes were advertised

under pressure from the tobacco industry, which claimed

in different media (e.g. newspapers, billboards and televi­

they have the right to give information to consumers on

sion commercials) by simply avoiding direct mention of

the quality of their products, e.g. lower nicotine and tar

smoking, cigarettes, brand names, etc. Additionally, the

levels.)

implementation of the advertising ban was poorly super­

The Croatian Government may decree one-time exceptions

vised and penalties were decidedly low for firms that were

to this ban on tobacco and tobacco product advertising,

caught and fined for violating regulations.

and this solely for sporting events of international impor­

tance. [Note: The Government only issued such a decree

Realizing that tobacco is the major avoidable health risk

several times for international motor-bike-crosses and auto

and cognisant of weaknesses in the existing regulations,

rallies so that Croatia was not left out of these international

the Ministry of Health initiated the drafting of a new

sports events.)

law. In November 1999, the Croatian Parliament passed

a Tobacco Product Use Restriction Act, which contains

Article 10 stipulates:

the sections: (i) General Provisions; (ii) Noxious Cigarette

No smoking of tobacco products is allowed during live tel­

Ingredients and Mandatory Health Warnings on Tobacco

evision shows. The press may not publish any photographs

Products; (iii) Restriction Measures for Tobacco Product

or drawings of people smoking for advertising purposes.

World Health Organization

Therefore, the law has placed a complete ban on direct

and indirect advertising of smoking in practically all media,

barring special cases related to international sporting
events (international motor-bike-crosses and auto-rallies).

The only unspecified media left is the electronic media, the

smoking was, especially considering the pollution people
lived with. They also questioned the truthfulness of study
results concerning the impact of smoking on health, saying

that those who initiated this Act did not consider people
who made their living growing, manufacturing or selling
tobacco, or whose salaries partly depended on tobacco

share of whose use three years ago was significantly small­

revenue. Some press articles suggested that advertising

er than now. Moreover, the past practice did not point to

was a way for the tobacco industry to inform customers

these media being a problem.

about their products' quality and business results, etc.

According to this Act, sanitary inspection assumed oversight

Furthermore, writing in one of the major Zagreb daily

of adherence to the advertising regulations in Articles 9 and

newspapers, one of the more well-known journalists

10. When the Act passed in Parliament, sanitary inspec­

directly attacked the professionals who had prepared the

tors began overseeing the implementation of the Articles'

Act for disregarding journalists' income, arguing that if

regulations. Because the fines were high, tobacco advertise­

journals and magazines are paid to advertise tobacco, it

ments disappeared from the media within a few months.

will raise their income and journalists' salaries as well.

The implementation's steps
With the aim of promoting the population's health and

alleviating the health impact of smoking, and prompted
by the World Health Organization (WHO) as well as the
success of other countries in the area of tobacco control,

Croatia's Ministry of Health has initiated the drafting of
the Tobacco Product Use Restriction Act.

The intervention's success
It should be emphasized that from the outset of the

Act being drawn up (the procedure taking over a year)
the tobacco industry intensified its advertising activities

and ran a campaign called «What are we silent about?»

During the campaign, they availed themselves of every
means to advertise smoking indirectly, in practically every

During the law-making procedure, the Minister of Health,

media, something not prohibited by previous legal provi­

the various professionals who drew up the Act, and dis-

sions. Use was made of likeable characters calling for

ease-prevention-oriented health specialists explained the

silence either onomatopoeically or through mime, show­

Act's intentions in medical journals, at professional and

ing, in addition, how enjoyable they found it to smoke.

public gatherings and in the mass media, etc.. They also
warned of the health consequences of smoking and made

use of other countries' best practices in tobacco control.

The passing of the Tobacco Use Restriction Act was
promptly followed by the disappearance of the 'Whatare-we-silent-about?' campaign's likeable characters, who

This Act was relatively long in the making, because

ing-related advertisements. This is understandable in view

the public that tobacco constitutes an important sector of

of the stiff fines for breaking the law. Specifically, a legal

agriculture and industry, one which contributes heavily to

the national budget. (For example, in 2001 the value of

person contravening the complete ban on tobacco product
advertising can be fined between Kn 200 000 and Kn 500

non-manufactured tobacco was Kn 136 189 000 or 2.9%

000 (the approximate equivalent of between Euro 26 000

of the total purchased and sold agricultural, forestry and

and Euro 66 000) and responsible individuals within the

fishing products) (5).

legal person with 10 000 to 20 000 HRK (between Euro

The tobacco growers and tobacco industry further argued

1300 and 2600).

that introducing new regulations could lead to a reduction

Nonetheless, the tobacco industry's efforts to advertise

in the state's tax revenue and threaten the livelihood of

its products do not seem to have slackened. Last sum­

people who make their living from tobacco growing and

4

had advertised smoking, and, step by step, of other smok­

tobacco growers and the tobacco industry kept reminding

the manufacture and sales of tobacco products.

mer, a "Greeting from Rovinj" message appeared for a
while in different media. It is a picture of Rovinj, a colour­

In these activities they were joined by some journalists,

ful tourist resort on the Adriatic coast (which has a large

whose articles questioned just how harmful to health

tobacco factory as well). This raises the issue of whether a

Country report on advertising and promotion bans - Croatia

new attempt at sending ads, this time by hiding behind a
tourist advertisement, is involved. The suspicion was sup­

The special tax on tobacco products was introduced in July

ported by the as-yet-unchecked information that the two

out of the total of collected special taxes declined. For the

grey lines have appeared in patches on this message that

most part this has been ascribed to a fall in sales due to

could also be found on the paper inside of some cigarette

increased retail prices, but it could also be the result of an

packs from the Rovinj Tobacco Factory. Should this happen

increase in the sale of illicit tobacco products.

again, the Ministry of Health-appointed Commission for

Smoking Control plans to inform the sanitary inspection,
who is responsible for the implementation of Article 9, and

to undertake the penal provisions against the Rovinj fac­
tory if they are breaking the law.

1994. From 1996 until 2000, the proportion of this tax

In 2001, the special tax on tobacco products amounted to
Kn 2 094 696 000 or 27.4 of the total of collected special

taxes. Unfortunately, it was not possible to obtain the data

on the tobacco industry's advertising expenditures as well as
the impact of the Act on the media's advertising revenues.

Other impacts of the intervention
It must be emphasized that formerly Croatia also had cer­

tain legal provisions aimed at enabling tobacco control,

including the direct tobacco advertising ban. The influence

of tobacco advertising and promotion bans is impossible

to consider in isolation from other measures. The current
Tobacco Product Use Restriction Act, which came into

force in November 1999, banned direct and indirect adver­

Conclusions
Croatia's experience has demonstrated that gaining the
support and advocacy of leading professionals, decision­

makers and public figures is critical to passing laws that

ban direct and indirect tobacco advertising and promotion,
as well as limit the use of tobacco products.
The provisions banning tobacco product advertising and

tising as well as laid down noxious ingredient allowances

promotion have proven efficient, largely owing to the fact

in tobacco products, imposed the obligation for tobacco

that they are accompanied by adequate penal provisions

products to carry health warnings specifying the content

(stiff fines) and actually implemented. Unfortunately, elec­

of messages, instituted restrictions on the use of tobacco

tronic media is the loophole in this Act. Another problem

products, including a ban on smoking in all health and

is the sale of foreign reviews, which come from countries

educational institutions and prescribed preventive meas­

with no ban on cigarette advertising. The same is true for

ures against smoking that include health education.

foreign TV programmes and for international sports and

It should be borne in mind that, according to information

available, the proportion of revenue from a special tax on
tobacco products (99.9% of which relates to cigarettes)
has demonstrated the following trends during the period

1995-2001.

other events sponsored by the tobacco industry. A por­

tion of these take place in Croatia or are broadcasted on
TV. The Ministry of Health-appointed Commission for
Smoking Control plans to prepare the amendments to the

existing Act to close these legislative loopholes. It is defi­
nitely expected that the WHO Framework Convention on

Table 2. Trends in revenue from tobacco product tax

Tobacco Control (WHO FCTC) will be supportive to these
amendments.

% from special tax on tobacco

Year

products out of total special taxes

1995

35.5

1996

37.8

1997

37.0

1998

1999
2000

2001

33.6

32.0
27.0
27.4

World Health Organization

Table 3. Estimated percentage of deaths caused by smoking in Croatia, 2002, by sex and major cause of death groups

Chronic

Upper
Sex

All causes

All

Lung

aero-

Other

obstructiv

cancer

cancer

digestiv

cancer

pulmonary
disease

e cancer

M

diseases

Vascular

Other

diseases

causes

%

N

%

N

%

N

%

N

%

N

%

N

%

N

%

N

%

N

25

6433

43

3044

92

1924

66

481

15

645

75

428

14

93

21

2516

18

973

F

9

2235

13

650

72

356

36

34

2

89

53

161

7

40

6

883

7

294

Total

17

8597

30

3623

87

2250

60

494

8

693

66

577

10

123

13

3471

12

1162

'Cancers of the mouth, oesophagus, pharynx, and larynx.

Source: Tobacco or Health: A Global Status Report, WHO,
1997.

Croatian National Institute of Public Health

References
1. Kulcar Z, Kovacic L, Bedenic B. Rasprostranjenost pusenja u

stanovnistvu Hrvatske (Smoking prevalence in Croatian
population). Li/ecn Vjesn 1974; 96:467-72.

2. Turek S et al. A large cross-sectional study of health attitudes,
knowledge, behaviour and risks in the post-war Croatian
population (The First Croatian Health Project). Coll Antropol,

2001, 25:77-96.
3

Hibell B, Andersson B, Ahlstroem S. The 1999 ESPAD Report
The Swedish Council for Information on Alcohol and Other

Drugs, Council of Europe. Stockholm, 2000.

4. Hrabak-_erjavi_ V. Pu_enje - rizi_ni Jmbenik za zdravlje /
Smoking - the health risk factor/. Medicina rada i okoli_a I
Occupational health and environment/. Medicinska naklada,
Zagreb, 2002:391-395.

5. Staten Statistical Bureau. Statistical Yearbook. Zagreb, 2002.

6

Other

respiratory

Taxation (including
Smuggling

Control)

Tobacco Taxation and Smuggling
Control: New Zealand

WHO/NMH/TFI/FTC/04.02

pH' 13-

Tobacco taxation and smuggling control:

New Zealand
Murray Laugesen
New Zealand Health Ltd.

World Health Organization

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

WHO Regional Office for Africa (AFRO)

WHO Regional Office for Europe (EURO)

Cite du Djoue

8, Scherfigsvej

Boite postale 6

DK-2100 Copenhagen

Brazzaville

Denmark

Congo

Telephone: +(45) 39 17 17 17

Telephone: +(1-321) 95 39 100/+242 839100
WHO Regional Office for South-East Asia (SEARO)

WHO Regional Office for the Americas / Pan
American Health Organization (AMRO/PAHO)

World Health House, Indraprastha Estate

Mahatma Gandhi Road
525, 23rd Street, N.W.

New Delhi 110002

Washington, DC 20037

India

U.S.A.

Telephone: +(91) 11 337 0804 or 11 337 8805

Telephone: +1 (202) 974-3000
WHO Regional Office for the Western Pacific

WHO Regional Office for the Eastern
Mediterranean (EMRO)

WHO Post Office

P.O. Box 2932
1000 Manila

Abdul Razzak Al Sanhouri Street, (opposite Children’s

Philippines

Library)

Telephone: (00632) 528.80.01

Nasr City, Cairo 11371

Egypt
Telephone: +202 670 2535

2

(WPRO)

4^

Tobacco taxation and smuggling control: New Zealand

From 1985 to 1998, consumption of tobacco products

Introduction

fell more rapidly in New Zealand than in other OECD

For over 100 years taxation has been a common method

countries as a result of reliance on taxation to increase rev­

of revenue collection in New Zealand and the major policy

enue’. However, compared to some countries, prevalence

instrument for reducing tobacco use since the comprehen­

did not fall as rapidly; before 1999 there was little support

sive tobacco control programme began in 1985'. Tobacco

to help smokers quit (e.g. there was no quit advertising

tax rates have been raised once or twice a year since

and no toll-free quit line).

that time2. A comparison of cigarette prices in relation

to income in the year 2000 showed that in New Zealand

The intervention—various types of tobacco

cigarettes were more costly than in 22 Organisation for

taxation increases and policies

Economic Co-operation and Development (OECD) coun­

Tobacco excise contributed 1.9% of the

tries, except for the United Kingdom3. During the 1986-

1992 recession, the Government increased the tobacco tax

to raise revenue.

Government's income in 2001.4

Periodic tax increases above the level of inflation (1800s

to the present day). Since the 1800s the Government has
Table 1. Smoking trends in New Zealand,
1976-1996

Years in
which

All males

Census

asked

% who

smoking

smoke

Tobacco product

All

Maori

Maori

females

males,

females

% who

% who

% who

per smoker

smoke

smoke

smoke

per day

Cigarette

consumption per

consumption

adult

Estimated
deaths from

cigarette

cigarettes or

smoking (as %

grams per year

of all deaths)

1976

40

36

56

59

24

3154

4114(16%)

1981

33

27

54

58

25

2905

4559 (18%)

1996

25

23

40

47

16

1512

4679 (16%)

-38

-36

-29

-20

-33

-52

14

question

% change

1976-

1996

Sources: Prevalence: New Zealand Census. Consumption per

levied increases in tobacco tax when it needed revenue.

adult age 75 years and over: Statistics NZ.

In 1958, the Government increased cigarette prices 42%

Attributable deaths: Peto et al. 1994; and thereafter by

and also increased alcohol taxes heavily. Consumption

Laugesen M.

fell by 13%; this was before health warnings were placed

Note: Maori, the indigenous people of New Zealand, comprised

15% of the total population in 2001.

’ Laugesen M, Swinburn B. New Zealand's tobacco-control

programme 1985-1998. Tobacco Control 2000. 9: 155-

The lung cancer death rates fell from 1975 onwards for men,

162. www.tobaccocontrol.com

and from 1992 for women under 70.
The estimated number of cigarette deaths was still increasing

2 Laugesen M. Tobacco Statistics 2000. Cancer Society of

in 1996, due to the ageing population, but the cigarette death

New Zealand, www.cancernz.org.nz

rate continues to fall in line with the lung cancer death rate.

(See Surveillance and monitoring).

3 Health New Zealand international tobacco control
database, 1960-2000. www.healthnz.co.nz

4

Budget revenue tables year to June 2001.
www. treasury.govt nz

3

World Health Organization

on cigarette packets. Such a low decrease in consumption

ufactured cigarette. In addition, a goods and services tax is

response was good for revenue, but not so effective for

applied to all goods and services, at the rate of 12.5% of

health. The Government was defeated in the next election

the final retail price.

and forced to decrease cigarette prices slightly. By 1960

consumption was rising again, thanks to cigarette advertis­
ing, lack of health warnings, competition between trans­
national tobacco companies and the new filter cigarettes.

Hand-rolled cigarettes made up 26% of all tobacco used
in 2001. Pipes and cigars accounted for 1 % of tobacco
used, and oral tobacco is banned. But without the uniform

rate of tobacco tax by tobacco weight in place, shifting to

1960-1983. Without regular cigarette price increases, cig­

hand-rolled cigarettes would provide a way to avoid quit­

arettes became cheap relative to the price of other goods.

ting, in the face of a tax or price increase on manufactured

1984-1989. As inflation became more severe, keeping

cigarettes.

the real price from slipping became even more important.

A refinement of this method is to review the taxed weight

Large catch-up increases were needed.

of tobacco in manufactured cigarettes, and if it were, for

1990-2002. Finance Minister Caygill had obtained chang­
es to the Customs Act to require automatic regular annual

increases in tobacco tax to adjust for inflation from 1990

example, to fall to about 0.6g tobacco as in Swedish or
Finnish cigarettes, to decrease the rate of tax to 60%—not

80%—of the per kilogram rate.

onwards. The cigarette companies supported this reform.

The goods and services tax includes tobacco. It makes up

This added up to a 20% increase in tax over the decade

one-ninth of the final retail price. As this tax is aimed at all

1990-2000, which health groups did not have to particu­

goods and services, it does not increase the price of tobac­

larly ask for, releasing parliamentary time, and enabling

co compared with other goods. However, any increase in

health lobbyists to focus instead on periodic price increases

tobacco tax causes follow-on increases in the goods and

over and above the level of inflation.

services tax—a tax on a tax.

Annual or six-monthly adjustments of the tobacco tax

Tied-tobacco tax. Until 2002 there was no direct cents-in-

rate for inflation (1990). These adjustments, which are

the-dollar levy that was written into law in New Zealand

almost always increases, maintain the real tax rate and

for allocating tobacco taxation revenue to tobacco control

price of tobacco products rather than increase these above

or the treatment of smokers' diseases. The Treasury has

the level of inflation.

traditionally opposed tied tax, though such levies are in

A uniform tax rate across all tobacco products, accord­

place for alcohol and gambling.

ing to tobacco content (1995). Before tobacco tax reform

Correction for increased affordability. There is no auto­

in 1989, tax was a mixture of ad valorem and specific

matic upward correction of the tobacco tax rate for

tax rates. Finance Minister Caygill reformed this to a sim­

increased wages, which often tend to push up demand.

ple specific rate of tax, based on tobacco weight of the

However, raising tax periodically above the level of infla­

product. Thus the price remains high whether the smoker

tion should take care of income growth and increased

shifts to a lower-priced brand or to hand-rolled cigarettes.

affordability effects on demand.

Today there are no extra levies in the form of import duty,
and no farm subsidies: tobacco is no longer grown in New

Zealand.

Hazardous substances or toxicity taxes. Though not a pol­
icy in use in New Zealand, a "pollution tax” or toxicity tax,

on hazardous chemicals in smoke could provide a financial

The uniform rate of tobacco tax when raised in December

incentive that could be rapidly applied, as an alternative

2002 was NZS 324.50 (approximately USS 175.00) per

to regulatory control over (independently tested) levels of

kilogram of tobacco, applied whether the tobacco is in

leading hazardous substances in mainstream smoke. An

cigars, pipes or cigarette tobacco. For manufactured ciga­

example of this would be hydrogen cyanide gas, arsenic,

rettes, which contain just under 0.8g of tobacco, the same

rate also applies, as the tax rate per 1000 cigarettes is

calculated as 80% of the tobacco tax rate per kilogram. In

2002, each cigarette was taxed currently at 26 cents per

cigarette, which amounts to 60% of the current retail price
4

of 43 cents for the Holiday brand, the most popular man­

5

Fowles J, Barker M, Noiton D. The chemical constituents

in cigarettes and cigarette smoke: Priorities for Harm
Reduction. A report to the Ministry of Health, March

2000. Porirua: ESR. www.ndp.govt.nz

Tobacco taxation and smuggling control: New Zealand

and the carcinogen 1:3 butadiene5. Taxing actual tar or

The effect of the intervention

nicotine yields is not helpful, but taxing the ratio of the

hazardous substance to nicotine yield makes more sense,
since smokers smoke up mainly to get more nicotine.

The effect of taxes on cigarette prices

In New Zealand after past tax increases, the tobacco trade

(comprising manufacturers, wholesalers and retailers), tra­
The key steps

ditionally raised its share of the cigarette price by as much

Budget planning begins six months beforehand. The

Treasury decides with the Minister of Finance whether the
country's finances require extra revenue from tobacco.
Specialist anti-smoking groups such as Action on Smoking
and Health, the Smoke-Free Coalition and Heart, Cancer

as or almost as much as the tax increase. As tax made up

over half of the retail price, a tax increase of 23% in 2000
resulted in a packet price increase of 20%. The cigarette

companies increased their prices within a few days, and
sales fell within a week of the tax increase (Figure 1).

and Asthma charities, in their lobbying emphasize the pre­

The effect of taxation on consumption

mature death toll from tobacco, and urge the Minister of

As Figure 1 shows, in 1991, 1998, and in 2001, when the

Health to support an increase in tobacco tax. In fact, the

price rose by a dollar or more per packet, the number of

Minister of Finance is usually the prime mover, and the

cigarettes sold fell immediately after the price increased by

Minister of Health sometimes wins a share of the increased

approximately 2 million cigarettes a week. Cigarette prices

revenue for tobacco control programmes.

in the years between these graphs increased in line with

The tobacco companies, without publicity, also lobby the

Minister of Finance to not increase the tobacco tax rate,
emphasizing their huge current contribution of tobacco

excise and corporate income tax to the Government cof­

inflation, due to annual automatic adjustments of tobacco
tax. This allowed for increases in the all-items consumer
price index, which increased by 13.5% between graphs A

and B, and by a further 1.2% between graphs B and C.

fers. Companies also have made contributions to political

parties, though no New Zealand evidence has come to

light that undue influence was obtained in this way.

Figure 1. Weekly manufactured cigarette sales before and after tax-triggered price increases

in 1991, 1998 and 2001, New Zealand

A. Budget cigarette tax increase 1991

B. Budget cigarette tax increase 1998

tax increased in week 9
Source: Table 2, and AC Nielsen weekly supermarket national

sales and retail price for 20 cigarettes in current dollars.2

5

World Health Organization

Figure 1 shows that:

When alcohol and socializing was at a holiday high, quit­

- the consumption falls dramatically after a well-publi­

ting was less likely. Health groups are not in the habit of
emphasizing unpopular price-increase news to smokers.

cized major price increase;

Governments do not wish to publicize their tax increases.

- the decrease is seen within a week of the price

Weekly sales data showed no decrease at all. Yet similar­

increase; and

sized increases in tax in 1988 at government budget time

- the smoking public's responsiveness to the price rise
has increased over time.

or soon after had resulted in decreased consumption—

probably because of publicity surrounding the annual gov­

ernment budget.

C. Pre-Budget cigarette tax increase 2000

As price increased in response to the tax and price rise, the

number of cigarettes sold decreased.
10 J

10

Each of the tax increases in 1991, 1998 and 2000 was fol­
lowed within a week or so by a similar increase in price by

9

the tobacco trade.

The volumes of cigarettes sold fell to a new level within
one week.

6

1

2

3

4

5

6

7

8

9

■ Price
—— Millions sold

As shown in Table 2, price rose 20%, and sales fell 16%.

10

16/20 = 80% price responsiveness.

11

12

13

Source: Table 2, and AC Nielsen weekly supermarket national sales
and retail price for 20 cigarettes in current dollars.2

Table 2. Changes in response to major tax-triggered cigarette price increases in 1991, 1998,
and 2000

Change in cigarette price (a)

Change in volume cigarette
sales (b)

Price responsiveness (b)/(a)

1991

16.3%

-10.5%

0.64

1998

13.3%

-9.6%

0.72

2000

20.2%

-16.1%

0.80

Source: AC Nielsen weekly supermarket national sales and retail
price data.2

Example 2: the effect of annual tax increases on sales.
No publicity, no quitting

Example 1: the effect of a notified but unpublicized tax
increase. Smokers respond to the perceived rise in price.

A 20-cent rise in tax per packet that had been notified
by the Finance Minister six months before went unnog

ticed on 1 January 1989, during annual summer holidays.

These adjustments for inflation sometimes equal to a retail

price increase of 2%-3%, and take effect on 1 December.

The timing is not ideal for quitting as: retailers are starting to
discount cigarettes before Christmas and New Year; smokers
are pre-occupied with preparation for Christmas and vaca­

tions; and quit line advertising support tends to be less, due
to higher television advertising costs during this season.

Tobacco taxation and smuggling control: New Zealand

Example 3: trade-induced price increases. The consumer

while the gross revenue of the tobacco trade (retailers,

price index increased by 2.65% in the year to September

wholesalers and manufacturers combined) decreased 18%.

2002. As required by law, the tobacco tax rate was
increased by 2.65% on 1 December. Within a week, the

price of cigarettes increased not by 2.65%, but by 30-40

Figure 2
Smoking population, any cigarette, New Zealand 2000,
quarterly data

cents per pack, or to 3.6% to 3.9% above the previous

price, as the manufacturers set a new recommended retail
price to retain their percentage share of the packet price.
The price increase occurred without publicity, and though

some callers to the quit line mentioned price as a reason for
calling, the number of calls to the quit line in the first week
of the new price did not increase. We conclude that even

if smokers noticed the unpublicized price increase at the
beginning of the year-end busy holiday-shopping season,
they were just too busy to think about quitting at this time.

The effect of tobacco taxation on smoking
prevalence
Example 4: the effect of a sudden but well-publicized

price increase (Figure 2).

On 12 May 2000, a sudden cigarette tax without prior

warning triggered a cigarette price increase of 20%. The

surprise timing was deliberate, to maximize revenue.
Publicity was intense because of the size of the increase—
approximately NZ$ 1.40 for a packet of 20 cigarettes.

Smokers were angry and unprepared to quit. Cigarette

sales fell 16%. Prevalence fell three percentage points.
An estimated 80 000 (one in eight) smokers quit smoking

Source: AC Nielsen and Roy Morgan Research data combined.
Comment: From April to June the smoking population was sig­
nificantly less than in the other quarters. (pcO.001). In quarters
2 and 3 taken together, the smoking population was signifi­

cantly less than for quarters 1 and 4 combined. (p<0.001)

in the second quarter of 2000, but prevalence returned

During this time, sales volumes (consumption) per adult

to "normal" after about four months. The Treasury did

fell 42%.

not warn the Quit Campaign since the tax increase came
under budget secrecy. The Quit Campaign was not target­

ed to, or able to prevent the relapse of this large number
of smokers. This occurred before the Government subsi­

dized Nicotine Replacement Therapy (NRT).

Quitting even for four months by one in eight smokers is a
major event. The challenge is to plan to help these smok­

ers stay smoke-free for longer. The private pain of smok­
ers grappling with addiction and the economic stress of

smoking, may need to be converted into an annual staged
planned-for community event with mass media and the
media-promoted support of family and work colleagues,

Revenue increases, smoking decreases
As tobacco tax rates were increased, tobacco tax revenue

rose in real terms in New Zealand from 1980 onwards, and
the number of cigarettes smoked decreased (Figure 3).
Thus, tobacco taxation helped improve revenue and health

at the same time.

Tax for revenue or for health?
Major tobacco tax increases above the level of inflation

were introduced for a combination of reasons:
- in 1986, 1988, 1989 and 1991 to increase revenue

during a recession;

and with subsidized NRT available.

- in 1995 as part of policies to curb youth smoking;

Effect of tobacco tax on revenue to the Government and

- in 1998 to increase revenue; and

the tobacco trade

- in 2000 to increase revenue and to accompany, and

From 1990 to 2001, measured in constant dollars, govern­

possibly pay for, new expenditure on Maori quit­

ment tobacco tax revenues increased an estimated 15%,

smoking programmes.

World Health Organization

Figure 3
Tobacco products revenue and consumption, 1980-2002

14 to 15, students are price sensitive; those receiving more
pocket money were more likely to be smokers6. The price

of cigarettes may affect those youth smokers who feel the

need to buy a packet of cigarettes every day or so, and an
increase in price may delay these smokers' progression to
adult consumption levels.
But from ages 15-24, despite low affordability for many
in this age group, smoking rates are reaching their highest

levels’.

Recent and planned policies for tobacco taxation
1

Making the policy more palatable to smokers

As cigarette prices rose in the 1980s and 1990s, further
taxes became less attractive politically, as many people felt
smokers were being taxed but not being helped to over­

come their addiction. However, in 1999 the Government

funded a Quit campaign and quit line and in 2000 sub­
sidized nicotine patches and gum. These moves demon­
strated to smokers that the Government and the national
tobacco control programme were willing to assist smokers,
and not just to regard tobacco tax as the best way to meet

revenue needs.
I

” Clgarettes/adult
I Tobacco tax revenue in millions NZD

In 2000, smokers phoned the quit line, angry because the
price had risen. However, by later in the year 2000 they
were offered a much cheaper way of accessing nicotine

Source: Treasury, letter of 5 July 2002, and Tobacco Facts www.

(gum or patches) for several weeks while they quit, thus

ndp.govtnz. Calendar year data with the exception being that

hopefully avoiding the tax altogether in future. In 2000,

2002 data are for the 12 months to June. Excise revenue as

7% of all smokers called the quit line for advice on quitting.

well as customs revenue (an extra 5%) is included since 1995.
Revenue was deflated to 1995 prices using the all-items con­

2

sumer price index.

age of tax and quitting

Decisions to use the increased revenue from any increase

in the tobacco tax, to fund tobacco control programmes,

as in 1995 and 2000, were made at the cabinet table, but
not written into statute as a percentage of the increase in
tobacco tax.

Making the policy more health-effective: planned link­

- From 1970 when health was first mentioned by the
Finance Minister as a reason to tax tobacco, to 1995
when the Health Minister actually introduced the
tobacco tax bill into Parliament to help pay for youth

smoking programmes, tobacco tax was increasingly
regarded as a health issue. But more often than not,

Effect on youth smoking

the primary purpose was revenue collection, and

One of the main justifications for tobacco tax increases has

the health aim often used to justify taxing smokers

been to discourage young people from smoking. At age

to make up a revenue shortfall. Health groups did
not object, because they knew that a higher price

6

Scragg R. Cigarette-smoking, pocket money and socioeco­
nomic status: results from a national survey of 4th form
students in 2000. New Zealand Medical Journal, 26 July

2002; 115 (1158) www.nzma.org.nz under Journal.
7

8

Laugesen M, Sheerin J. Tobacco Statistics, 1991.

for tobacco was necessary to discourage adolescent
smoking.

- Once the price has been raised to deter adolescents,

and the Government aims to make the first goal of

tobacco taxation smoking cessation and the second

Wellington: Department of Statistics, Department of

goal revenue, then a planned approach is necessary

Health.

so that quitting services can be strengthened for

I

Tobacco taxation and smuggling control: New Zealand

when the cigarette tax is raised. In addition, assum­

usually attributed to price, but now smokers face

ing a media campaign is established to persuade

cigarette packet warnings, the example of doctors

smokers to quit and stay quit and a well-publicized,

not smoking, health advertising combined with no

toll-free quit line is in place, will this increase or

tobacco advertising8, and social pressures and gov­

decrease tobacco tax revenue?

ernment assistance through the quit line, to quit.

- Figure 2 shows how a price increase induced a fall
in prevalence for four months, after which the mass

tobacco control programme. The huge peaks in quit­

quitting led to mass relapse. With open planning for

ting following a price increase suggest that unless

a notified future tax increase, more quitting support

there is already constant encouragement from mass

can be planned, to make every tax increase day into

media to quit, many smokers will wait for a price

a mass quit day—for example, annually, on World
No Tobacco Day. The United Kingdom has an annual
No-Smoking day, but tobacco tax increases have

never coincided with it.

3

- Price increases are an essential part of an effective

Making the tax and quit policy more attractive to the

increase before quitting.

- A strong, comprehensive tobacco control programme
is likely to increase the health effects of a given price

increase, maximizing quitting and decreasing ciga­

rette consumption, which translates into cleaner air

Minister of Finance.

to breathe at home and more money freed up for

Periodic "Big bang" tobacco tax increases do lower con­

food. Thus, governments wishing to soften the harsh

sumption dramatically, at least for a while, as they attract

effects of raising the cigarette tax on poor smokers,

media publicity. But smaller, more regular tax increases

assist most by strengthening other tobacco control

are also effective in proportionately lowering consump­

tion - and in gaining revenue, with less political cost to

measures.
Increased price responsiveness means more health gain,

the Government from smoker voters. Repeated smaller-tax

less revenue gain

increases give smokers more opportunities to quit, and

From a revenue-gathering perspective, increased price

quit line support is more likely to be able to cope.

responsiveness of smokers means that the tax level per

A minister of finance who seeks increased revenue from

cigarette has to be increased more than previously to col­

tobacco tax can expect smokers to be angry when the

lect the same revenue, since the new prices shrink the

price rises by a dollar a pack, as happened in 2000. This

smoking tax base for raising the revenue.

is the price of gaining the revenue, since all taxes are

Eventually, governments may have to rethink the pur­

unpopular. Health groups and officials in other years

poses of tobacco tax, put less emphasis on revenue, and

sought more regular increases but by a smaller percentage,

give more weight to the health gains, which continue to

say 5% per year. Provided the tax rate is already adjusted

improve as the price increases.

for inflation, and the increase in publicized consumption
will decrease, and if smokers are also provided assistance

Higher tobacco taxation levels have not yet decreased rev­

to quit, the political cost of taxing tobacco will be greatly

enue in any jurisdiction.

lessened.

Conclusion

The World Health Organization (WHO) recently called for

New Zealand has had a long history of frequent tobacco

a 5%-10% annual increase in tobacco taxes. A 5% annual

tax increases. The following refinements have been put in

increase in price would double the price in 13 years.

place or have been proposed for consideration:

The price responsiveness of tobacco consumption

- The price sensitivity of cigarette sales to increases in

- Automatic adjustment of the tobacco tax rate for

inflation is a feature of tobacco taxation in New
Zealand and some other countries. If the inflation

tobacco tax (sales percentage decrease divided by the

rate in the preceding year was 2%, the tax rate rises

price percentage increase) rose from 30% in 1958

by that amount.

(no warnings, no advertising restrictions, few health

posters) to 80% in 2000 (Table 2). This change is
8 Smoke-free Environments Act 1990. www.ndp.govt.nz

- A uniform tax per gram of tobacco, from 1995

across all tobacco products, represented another
important improvement in tobacco tax policy, in

decreasing smokers' tendency, when cigarette prices

World Health Organization

rise, to shift to cheaper cigarette brands or to handrolled tobacco, instead of quitting.

- The reliance on a specific rate of taxation (dollars
per 1000 or per kilogram) introduced around 1989
makes for decreased price differences between

brands, thus discouraging brand-switching as a sub­
stitute for quitting.

- The provision of full quitting support to help smok­
ers who face regular, planned tax increases and quit

days, for example, every World No Tobacco Day,

seems a logical and feasible next step, if tobacco tax
is to be valued for its health-gain advantages, rather
than for the revenue gain.

Smuggling—inbound and outbound

Compliance with revenue collection and smuggling of
exports

With only two tobacco factories and few ports as well as

a simple system involving a specific rate of tax, achieving
compliance in collecting tax is not difficult. There is no
provision at present to tax cigarettes intended for export
and refund the tax once excise tax is paid in the country

of final destination. The Canadian Finance Ministry has

promoted such a scheme to discourage "disappearance"

of exported cigarettes into illegal smuggling channels
worldwide. New Zealand exports are small scale and main­

ly to the South Pacific.
Smuggling of imported cigarettes

New Zealand, separated by 2000 kilometres of ocean
from other landmasses, seized over 2 million cigarettes in

2001-20029, out of total sales of over 3388 million ciga­
rette equivalents in 2001. As tobacco is no longer grown

commercially, evasion of duty from local cultivation is eas­
ily detected, and of small scale.

’ Customs foils cigarette smuggling. News release, 6 June
2002, at web site: http://www.aistoms.govt.nz

Advertising and

WHO/NMH/TFI/FTC/04.04

Promotion
Bans

Country Report on Tobacco Advertising
and Promotion Ban-Botswana

Country report on tobacco advertising
and promotion ban - Botswana
Bontle Mbongwe

Principal Health Officer
Ministry of Health, Gaborone, Botswana

World Health Organization

World Health Organization

r
Tobacco Free Initiative Headquarters would like to thank the Regional Offices
for their contribution to this project.

WHO Regional Office for Africa (AFRO)

WHO Regional Office for Europe (EURO)

Cite du Djoue

8, Scherfigsvej

Bolte postale 6

DK-2100 Copenhagen

Brazzaville

Denmark

Congo

Telephone: +(45) 39 17 17 17

Telephone: +(1-321) 95 39 100/+242 839100
WHO Regional Office for South-East Asia (SEARO)
WHO Regional Office for the Americas / Pan

American Health Organization (AMRO/PAHO)

World Health House, Indraprastha Estate
Mahatma Gandhi Road

525, 23rd Street, N.W.

New Delhi 110002

Washington, DC 20037

India

U.S.A.

Telephone: +(91) 11 337 0804 or 11 337 8805

Telephone: +1 (202) 974-3000
WHO Regional Office for the Western Pacific
WHO Regional Office for the Eastern

(WPRO)

Mediterranean (EMRO)

P.O. Box 2932
WHO Post Office

Abdul Razzak Al Sanhouri Street, (opposite Children's
Library)
Nasr City, Cairo 11371

Egypt
Telephone: +202 670 2535

2

1000 Manila
Philippines
Telephone: (00632) 528.80.01

f

Country report on tobacco advertising and promotion ban—Botswana

1. Overview of tobacco control activities
in Botswana

institutions, public transportation and passenger lounges.
The legislation also prohibits tobacco advertising and sales

of tobacco products to persons under 16 years of age. To
The Government of Botswana has long recognized and

ensure the smooth implementation of its provisions, the

accepted the need to sensitize its population to the harm­

Act also established a committee whose primary role has

ful effects of tobacco. The Primary Health Care approach,

been to advise the Minister of Health on all matters relat­

adopted in the 1970s in Botswana after the 1978 Alma

ing to tobacco smoking.

Ata Declaration emphasized this requirement However,

the theme "Tobacco or Health", launching the first World
No Tobacco Day on 7 April 1988 in Botswana, marked
the beginning of an intensive anti-tobacco campaign in
the country. Since then, World No Tobacco Day has been

held annually on 31 May. The commemoration of World

No-Tobacco Days together with other educational pro­

grammes aimed at different sectors of the population and
the general public, have contributed to sensitizing the
general public about tobacco products’ harmful effects on

human health and fostered a positive political climate. This
has led to the development of a comprehensive tobacco

Following the enactment of the law in 1992, several

major developments took place. In 1993, a National

Coordinating Committee (NCC) responsible for imple­
menting the Act was established. The NCC's membership

included government representatives from the Ministries
of Home Affairs, Agriculture, Health, Transport, Trade and

Industry and the private sector—the Botswana Federation
of Trade Unions (BFTU) and the Botswana Confederation

of Commerce, Industry and Manpower (BOCCIM). The

activities of the Committee include sensitization of the dif­
ferent population groups on the health effects of tobacco
and on the requirements of the CSA.

control programme in Botswana.

In December 1992, the Government of Botswana enacted
its first law on tobacco and tobacco products—the Control

of Smoking Act (CSA). The intention of this Act is to
control smoking in enclosed public places, which include

licensed premises, government and private offices, health

The national airline Air Botswana was the first to respond
to the provisions of the Act by banning smoking on all its

domestic flights in 1993. In 1995 the Airline expanded the
ban to all flights within the Southern African Development

Community (SADC) region.

Figure 1
Cigarette imports (kg)

Cigarette (kg)

|

| adjusted quantity (kg)

World Health Organization

In 1997 a major campaign to create smoke-free work­
As part of its sensitization activities, the NCC organized its

places was launched. It comprised training managers in

first stakeholder workshop in 1994 aimed at familiarizing

workplaces on how to develop workplace smoking poli­

senior government officials, the private sector and com­

cies and sensitizing them to the importance of protecting

munity leaders with the Act's provisions and the actions

non-smokers from the harmful effects of tobacco. The

required from them. Particularly important at this work­

education campaign also linked smoking with productiv­

shop were issues related to the Act's requirement that

ity, enlightening managers on the effects of smoking on

every employer prepare in writing, a workplace smoking

their organizations' performance. In 2001, a survey assess­

policy in consultation with the employees. The primary

ing the implementation of the CSA and, in particular, the

objective of the workplace smoking policies is to ensure

establishment of workplace smoking policies was carried

that employees who do not smoke or who do not wish

out. The survey showed that 91.0% of private compa­

to smoke in their workplace are protected from tobacco

nies had such policies, 77.0% of which were written.

smoke. As a result of this workshop a positive response

The majority of the written policies were done after 1997

was received from both Government and the private sec­

(Figure 1).

tor. During the same year (1994) the Directorate of Public
Service Management issued a Directive, which prohib­

ited smoking in all government offices and government

vehicles. Smoking was also banned on public transport in

2. Tobacco-growing and use in Botswana

1994. One of the major commercial banks, Barclays Bank

of Botswana, also responded to the call by banning smok­

Botswana is not a tobacco-producing country. However,

ing in all its banking halls.

different types of tobacco and its products are imported

Table 1. Quantities (Kilograms) of various tobacco products imported into Botswana

Product

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

Tobacco
(not stemmed/
stripped)

70856

143886

24005

35934

88391

28689

8149

29502

432363

35396

Tobacco
(partly stemmed/
wholly stripped

63559

44957

92739

174166 134478

193044 224634

127570

2795

33801

Tobacco refuse

74603

123

162780

Cigars, Cigarillos

45940

104659

Cigarettes

0

341

44412

23307

11750

101085

182494

976258 773918

28214

34234

22512

45935

15521

61073

121109 323199

2632

3432

7929

5341

2253

1588

1461

315863

Smoking tobacco
(tobacco
substitute)

630203

149560

28005

26192

24920

4985

6426

9086

8868

3851

Cigarettes,
cheroots, cigarillos
& cigarettes
(containing tobacco
substitutes)

66927

89132

110118- 81985

80026

59916

62444

53717

80687

78229

Homogenized/
reconstituted
tobacco

2508

33722

30052

3572

29477

2843

613

6252

54603

99653

Other

55420

26956

21705

25462

21206

22650

71670

90649

83841

176961

4

Source: Botswana Trade Statistics

Country report on tobacco advertising and promotion ban—Botswana

from neighbouring countries such as South Africa. There

ing and non-smoking areas. This situation therefore justi­

are also a limited number of households that grow tobacco

fies the high exposure (60%) of students to environmental

for their own consumption and sales to households with­

tobacco smoke (ETS) in public places.

out tobacco gardens on a restricted scale. Although there
are no data on tobacco consumption in Botswana, there is
evidence that most of the tobacco and tobacco products

imported into Botswana are consumed domestically. Data

from the Central Statistic Office (1993, 1996) have shown
that over a five-year period (1992-1996) less than 2% of
tobacco and tobacco products were legally exported (re­

exports) to other countries. Table 1 shows quantities of

It is now well documented that the use of tobacco and its

products increases a person’s risk of contracting a number
of diseases. There is a relationship between tobacco use
and chronic diseases such as cancer. In a recent 18-month

study by Nashi and his colleagues (2001) 605 out of 911
patients diagnosed and treated for cancer in 3 referral hos­
pitals in Botswana were associated with tobacco use.

various tobacco products imported to Botswana between

1989 and 1998. It is evident from the table that ciga­

rette imports are significantly higher than other tobacco
products. However, a major reduction in the imports was

Tobacco advertising and promotion in
Botswana

recorded between 1991 and 1997.

Tobacco advertising and promotion activities appear both
Although data are available in Botswana on tobacco

to stimulate adult consumption and to increase the risk

expenditure, it is difficult to know the trends in consump­

of youth initiation. Research has shown that children buy

tion by age group, sex and population groups. However,

the most heavily advertised brands (Centers for Disease

available information shows that male-headed house­

Control, 1994), and are three times more affected by

holds (where the family considers the male as a head of

advertising than adults (Polay et al., 1996). Although there

the family) spend more on tobacco than female-headed

are no data specific to Botswana on the relationship of

households (i.e. where the family considers the female as a

tobacco advertising to tobacco consumption, studies in

head of the family) (Ndegwa, 1998).

the United States of America have shown that 34% of all

The prevalence of tobacco use among the youth has also

youth experimentation with smoking in California between

increased over the years. Traditionally, it is taboo for young

1993 and 1996 could be attributed to tobacco promo­

persons (school age) to be seen smoking in public, or at

tional activities (Pierce et al., 1998).

school. But over the years more and more young persons

The 1992 CSA prohibits tobacco promotion and adver­

have been observed smoking in public, and caught smok­

tising. This prohibition grew out of the high level of

ing in school. While we do not have data on the reasons

awareness at the political level of the harmful effects of

usually attached to the suspension of school children from

tobacco and the fact that tobacco growing is not one of

school, cigarette smoking is more often reported as the

the country's major economic activities. The Act prohibits

culprit for the suspension. A recent study of 1 920 sec­

the publication by persons or arrangement for any other

ondary school students in Botswana showed that 14.2%

person to publish any tobacco advertisement in Botswana.

of the students aged 13-15 were using some form of

Tobacco advertising, as defined by the Act, "means any

tobacco, 6% smoked cigarettes and 11% used some

words written, printed or spoken, or film or video record­

other form of tobacco such as cigars, chewing tobacco,

ing or other medium of broadcast or telecast, or pictorial

snuff and pipes (Botswana GYTS, June 2002). In the same

study, four out of ten students lived in homes where adults

smoke in their presence, and six out of ten were exposed
to smoke in public places.

The CSA restricts smoking in enclosed public places such

representation, design or device used to encourage the

use of or notify the availability of, or promote the sale of
any tobacco or tobacco products, or to promote smoking
behaviour." The National Tobacco Control Committee and

the Environmental Health Officers in Local Authorities and

as restaurants and other licensed premises, passenger

in the Ministry of Health currently administer all provisions

lounges and waiting rooms. It requires that 50% of an

of the tobacco legislation. These bodies together with the

eating hall be reserved for non-smoking customers. The

Police are also responsible for the enforcement of the ban

restriction, however, does not adequately protect the non-

on advertising and promotion.

smokers since there is no physical separation of the smok­

0

World Health Organization

gifts in the form of pens, ashtrays and other promotional
Since 1992, direct and indirect advertising of tobacco

products has not been permitted in Botswana. All tobacco
billboards were removed and no advertising was allowed

on the print media, radio or television. The current issue
of concern is cross-border advertising, which cannot be

material with logos of the different tobacco brands printed
on them. The companies also engaged in handing out free

cigarettes in malls, night clubs and hotels to members of
the public, including the youth.

addressed by national legislation alone. The tobacco indus­

Furthermore, in 1998, the tobacco agents intensified their

try is also finding ways of cutting into this prohibition by

efforts to use other forms of indirect advertising to recruit

brand stretching. Some of their current activities include

more smokers and encourage the use of other forms of

cigarette lighters made up as little dummy cigarette pack­

tobacco products. Sponsorship or event marketing, being

ets (Marlboro brand), clothing and household commodities

a form of promotion that is a key component of market­

such as ashtrays and menu holders in restaurants bearing

ing strategies for tobacco industries began to surface

brand logos (Marlboro in particular).

in Botswana. Sponsorship of sports and cultural events,

To address this problem, counter-marketing attempts

which are relatively cost-effective forms of advertising and

were made to offset pro-tobacco influences and increase

promotion, became the tobacco industry’s focus of atten­

pro-health messages and influences throughout the coun­

tion. The industry approached a few organizations offering

try. Counter advertising activities were therefore used to

them money to carry out their activities. However, this was

promote smoking cessation and decrease the likelihood

unsuccessful because of the public's high level of aware­

of initiation. The activities included media advocacy and

ness of the CSA's advertising and promotion provisions.

other public relations activities such as press releases and

The tobacco agents are cognisant of the advantages of

national and local health promotion activities and events.

event marketing over traditional advertising in heightening

While there are limited data to quantify the influence on

tobacco brand-name visibility, shaping consumer attitudes

public support for tobacco-free interventions, reports by

and communicating commitment to a particular life­

members of the public on violations of the provisions of

style. These events, which include sporting activities and

the Act, particularly smoking in public places are on the

music festivals, are often designed to appeal to the youth

increase. In 2000, employees in 16 private companies in

market, create good will for the tobacco industry through

the capital city of Gaborone reported such violations, fol­

association with sports and the arts, and to link tobacco

lowed by 42 in 2001. There has also been an increase in

use with exciting, glamorous and fun events.

the number of smokers and other tobacco users who want

$

to be assisted to quit. While a total of 255 smokers need­

ing help were registered in 2000, 449 were registered in

2002 nationally.

Successes of the intervention
In the late 1990s, the intensification of the tobacco indus­

try's campaign in Botswana threatened to defeat the

Implementation of the ban on tobacco
promotion and advertising

Government's determined efforts to control the use of

tobacco in the country. Tobacco imports, in particular ciga­
rettes, immediately fell in 1991, a year before the enact­

Although there are no tobacco industries in Botswana,
there are several sales agents for different tobacco brands.
Before the advertising ban policy was introduced, these

agents were responsible for advertising the products in

the entire country, including efforts to ensure that their
products were advertised and displayed in an attractive
and visible fashion in supermarkets and other retail outlets.

As soon as the advertising ban came into force, all adverts
and attractive displays of tobacco products were removed

ment of the CSA. Over and above a ban on tobacco adver­

tising, the Act restricts smoking in enclosed public places

and prohibits the sale of tobacco products to persons who
have not yet reached 16 years of age. Figure 1 shows a

reduction in cigarette imports between 1991 and 1997.
The intensified public education on tobacco and the harm­

ful effect it causes to its consumers could have also con­

tributed to this fall in cigarette imports. To date there have
been no reports of any violations of the advertising ban.

from supermarkets and other outlets.
Tobacco agents in Botswana have responded to this move

6

by engaging in other marketing tactics such as giving free

This success cannot be attributed only to the introduction
of le8ls|ation. It is also a result of the strong partnership

between the Government and the private sector. Through

Country report on tobacco advertising and promotion ban—Botswana

this partnership a high level of compliance achieved

increasing the demand for tobacco in the country. Second,

and weaknesses in the legislation were identified in a

the increase came at a time when South Africa, a neigh­

timely manner. The raised awareness of the legislation's

bouring country, was tightening its tobacco control laws.

requirements has empowered communities to report any

Third, we have observed the establishment in Botswana

anomalies they discovered, thereby making it difficult
for the tobacco industry to defeat government efforts.

of new tobacco agents to begin marketing their products.
It is therefore probable that more tobacco products were

For example, the organizer of the Miss Botswana Beauty

imported to Botswana due to the increase in the number

Pageant sent a representative to approach the tobacco

of tobacco agents that were otherwise based in South

control activities office in 2001 to enquire whether a

Africa. Lastly, even though this has not been confirmed,

tobacco agent based in Botswana could sponsor the pag­

the increase could be due to imports from South Africa

eant. In 2002, another representative from the Botswana

smuggled back into that country as a result of the tight­

Volleyball Association also enquired about sponsorship by

ened legislation. As indicated, the current data need fur­

a tobacco agent. Both organizations were approached by

ther verification from its source.

tobacco companies proposing sponsorship. The organiza­

tions, being aware of the advertising provisions of the

CSA, immediately sought advice from the Tobacco Control

office, in response to these enquiries the two organizations
were advised that the law does not allow any advertising

Limitations of the Control of Smoking Act
(CSA) of 1992

and that it is common practice for any sponsoring organi­

While the CSA has played a major role in the control

zation to be acknowledged during the event by way of

of smoking, particularly in restricting smoking in public

verbal or written communication. They were informed that

places, reducing tobacco sales to persons under 16 and

it was not advisable to allow such sponsorship since the

banning tobacco advertising, it has been limited in scope.

industry may want their products advertised, which might

There are difficulties in the language of the Act, such as

contravene the provisions of the law on advertising. There

the provision on smoke-free workplaces, which requires

have also been reports of the tobacco industry offering

the employer to consult with staff inputting in place a

sponsorship for music festivals in the country, but these

no-smoking policythat allows protection of non-smokers

never materialized. Although the tobacco industry offered

while giving smokers a place to smoke. Even though most

sponsorship to various organizations, it is heartening to

organizations have these policies, there are some practical

note that as a result of the general public’s awareness of

difficulties. The great success of bans on smoking in work­

the tobacco legislation and, in particular, the provisions on

places may have therefore been more the result of the

advertising, the industry was denied the opportunity to

intensive anti-tobacco campaigns and government direc­

advertise its products indirectly.

tives that followed immediately after the enactment of the

Through the involvement of organizations such as the

legislation. The CSA of 1992 never intended to achieve

Wholesalers Association of Botswana, compliance has

this objective, and was limited to creating a partial ban on

been successfully monitored within the retailing com­

smoking in the workplace, with accommodation for smok­

munity, ensuring that there were no tactics used by the

ers. While the advertising ban was successful, with adver­

tobacco agents in the country to promote tobacco use.

tising disappearing from the media, issues of cross-border

Partnership with local authorities and the media were also

advertising are not adequately addressed. The tobacco

some of the crucial aspects to compliance.

industry has found ways of cutting into this prohibition by

brand stretching. Smoking in restaurants and the restric­

Despite the successes we have had, we still have short­
comings, which need to be addressed constantly and in

tions on sales to children under 16 years old were also
some of the problematic areas of the 1992 CSA.

a sustained manner. A sharp increase in cigarette imports
was observed in 1998 and while it is fully acknowledged

The CSA empowered employees to complain to their

that the data may need to be studied further, there are

employers about violations of the Act in the workplace. But

a few factors that may be linked to this increase. The

this proved to be difficult if it was the employer smoking.

tobacco industry, being aware of the advertising ban

In practice, the Tobacco Control Office has been receiving

in Botswana, has used other forms of indirect tobacco

complaints and attending to them as best as it can.

advertising not explicitly covered by the law, thereby

While the Act has an elaborate scheme of fines, not a

Conclusions

single prosecution was ever brought by the police force.
This is despite the mechanism for admission of guilt, which

would have greatly facilitated enforcement of the Act. It
would be relatively easy to do random inspections of say
restaurants and issue spot fines to any establishment that

Comprehensive restrictions on tobacco advertising are nec­

essary to prevent the proliferation of messages and images
that attract people, especially youth to tobacco products.

Such restrictions are aimed at reducing the appeal of tobac­

does not comply with the 1992 CSA (the requirement of

co products, pre-empting the tobacco industry's efforts

separate smoking and non-smoking areas with signage).

to develop positive associations with tobacco products

Similar enforcement could be done for workplaces.

and thus help prevent their use and ensuing dependency
(Joossens, 1997). A comprehensive prohibition is considered

In 1999, the Government decided to revise the CSA to

cover the above issues, including aspects of advertising
such as sponsorship and other promotional activities not

explicitly covered by the 1992 CSA. The proposed new act

"The Tobacco Products Control Bill’' is intended to repeal
the 1992 CSA and to provide a comprehensive tobacco

control regime. Some of the issues addressed in it that
were not covered by the previous act include packaging

the most effective measure to achieve the policy objective.
All forms of advertising contribute to making tobacco prod­

ucts socially acceptable and desirable as consumer goods

and therefore represent an inducement to use tobacco
products. Consequently, alternative measures, such as a
partial ban, a ban on lifestyle advertising or a ban on adver­

tising aimed at youth, would not appear to be as effective.

and labelling prescriptions, comprehensive bans on adver­

Although there is no comprehensive data on the trends in

tising, prohibition of tobacco, promotion and sponsorships,

tobacco use and consumption in Botswana, there is evi­

anti-smuggling measures, taxation of tobacco products,

dence that a ban on tobacco advertising is an important

licensing requirements and litigation-enabling provisions.

component of comprehensive tobacco control. However,

The Act is currently being revised with the help of the
World Health Organization (WHO) and is nearing comple­
tion. The process of revision has entailed extensive consul­

tations nationally in the form of meetings among different
stakeholders involving government and nongovernmental

in addition to underscoring this importance, it is equally
essential to recognize why a ban on tobacco advertising
alone cannot work. The involvement of the communities
for which the legislation/ policy is developed and a strong

political commitment to tobacco control, are crucial for any

organizations (NGOs). The Botswana Government actively

intervention to work. To achieve the individual behaviour

participated in the negotiations of the WHO Framework

change that supports the non-use of tobacco, communities

Convention on Tobacco Control. Of major interest to

must be empowered to change the way tobacco is pro­

Botswana were the provisions of the Convention on

moted, sold and used. Effective community programmes

advertising, promotion and sponsorship. Botswana is one

must involve families, work places, schools, places of wor­
ship and entertainment, civic organizations and other pub­

of the countries strongly advocating for a ban on tobacco
advertising, including cross-border advertising. This has

lic arenas. The ban on advertising in Botswana has there­

been particularly so since it was the first to ban advertis­

fore succeeded due to the involvement of the communities

ing in the region but its efforts have been thwarted by

for which it was intended.

cross-border advertising from neighbouring countries. The

revision of the Act is a comprehensive one that covers all

other tobacco products not included in the 1992 CSA and
is in line with the provisions of the Convention.

In its effort to curb tobacco use, the Government of
Botswana has continued to focus on the need for national

and local action required to ensure the success of tobacco
control interventions. The Government acknowledges the

unique role played by the different sectors within and out­
side government in tobacco control efforts.
One of the major shortcomings of the tobacco control

programme in Botswana, however, is the lack of surveil­
lance to monitor the achievements of our primary goals.
These include prevalence of tobacco use among the dif­
ferent community groups, per capita tobacco consumption
and the prevalence of pro-tobacco influences, including

advertising, promotions and events that glamorize tobacco

Country report on tobacco advertising and promotion ban—Botswana

use. Specific evaluation surveys and data collection sys­

References

tems are also needed to evaluate our advertising ban. The
lack of financial and technical resources has led to this vital
component being left behind.

1.

efficacy both by deterring violators and by sending a

Botswana Government (1992) Control of Smoking Act.
Government Printer, Gaborone.

Enforcement of tobacco control policies enhances their
2.

message to the public that the leadership of the country

Centers for Disease Control (1994) Changes in Brand
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believes the policies are important. Tobacco advertis­

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ing, protection from environmental tobacco smoke and

restrictions on minors' access to tobacco, are some of the

3.

ban on advertising has worked for Botswana, it has done

Central Statistics Unit (2000) Trade statistics 1989 -2000,
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important areas requiring enforcement strategies. While a
4.

so because of the recognition that individual tobacco

Ndegwa SK (1998) Tobacco Control in Botswana: A situation
analysis. Unpublished.

control components must work together to produce the

synergistic effects of a comprehensive programme. A ban

5.

Pollay RW, Siddarth S, Siegel M (1996) The last straw?

on tobacco advertising, therefore, could not have achieved

Cigarette advertising and realized market shares among

the expected results without the needed community edu­

youths and adults, 1979 -1993. Journal of Marketing, 60:
1-16

cation and empowerment strategies in place.

A major lesson learned is that, when making policies on

6.

Pierce JP, Choi WS, Gilpin EA (1998) Tobacco industry promo­

tobacco control, regional cooperation and collaboration

tion of cigarettes and adolescent smoking. The Journal of

should be considered seriously. The issue now before

American Medical Association, 1998; 279 (7) 511-5.

Botswana is cross-border advertising, which has proved to

be difficult for the country to tackle alone.

7.

Joossens L (1997) The effectiveness of banning advertising

for tobacco products. Brussels, International Union Against

Cancer.

9

Taxation (including
Smuggling
Control)

Taxation Reform as a Component of
Tobacco Control Policy in Australia

WH0/NMH/TFI/FTC/04.01

pY\- '3-

0

Taxation reform as a component of
tobacco control policy in Australia
Michelle Scollo

and Ron Borland,
VicHealth Centre for Tobacco Control

V World Health Organization

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

WHO Regional Office for Africa (AFRO)

WHO Regional Office for Europe (EURO)

Cite du Djoue

8, Scherfigsvej

Bolte postale 6

DK-2100 Copenhagen

Brazzaville

Denmark

Congo

Telephone: +(45) 39 17 17 17

Telephone: +(1-321) 95 39 100/+242 839100
WHO Regional Office for South-East Asia (SEARO)
WHO Regional Office for the Americas / Pan

American Health Organization (AMRO/PAHO)

World Health House, Indraprastha Estate
Mahatma Gandhi Road

525, 23rd Street, N.W.

New Delhi 110002

Washington, DC 20037

India

U.S.A.

Telephone: +(91) 11 337 0804 or 11 337 8805

Telephone: +1 (202) 974-3000
WHO Regional Office for the Western Pacific
WHO Regional Office for the Eastern

(WPRO)

Mediterranean (EMRO)
WHO Post Office

Abdul Razzak Al Sanhouri Street, (opposite Children's
Library)
Nasr City, Cairo 11371

Egypt
Telephone: +202 670 2535

P.O. Box 2932

1000 Manila

Philippines
Telephone: (00632) 528.80.01

Taxation reform as a component of tobacco control policy in Australia

Introduction

should achieve two objectives. They should limit the abil­
ity of companies to undermine the tax increases and

In 1998, the Australian Government announced a major

restrict consumers' capacity to compensate when faced

reform of Australia's overall tax system. The previous sys­

with increased prices. The report describes the reforms

tem was characterized as out of date (it included a range

that were introduced and the effect these had on tobacco

of historically justified but now anachronistic taxes), unfair,

tax levels and prices. Data collected from mid-1997 for

discouraging of exports and investment, ineffective and

the purpose of evaluating Australia’s National Tobacco

complex. The proposed reforms included the introduction of

Campaign were used to make a preliminary assessment of

a Goods and Services Tax (GST) and the abolition of a raft

the likely contribution of price increases to recent declines

of state taxes and charges. The aim was to bring the serv­

in tobacco use in Australia and relate that to declines
attributable to other factors.

ice economy into the tax net, provide sustainable funding

to the states and lower corporate and individual tax rates.
Tobacco control advocates felt that it was essential to ensure

that this did not adversely affect tobacco taxation levels.

Tobacco users in Australia mainly smoke factory-made

cigarettes. Around 20% of smokers at least occasionally
purchase pouches of manufactured tobacco to make "roll-

Higher tobacco taxes significantly reduce cigarette smoking

your-own" (RYO) cigarettes. It is illegal to sell smokeless

and other tobacco use. However, for a specific tax increase

tobacco products, and only a small percentage of smokers

to have maximum effect on reducing consumption there are

regularly use pipe tobacco or cigars (Hill DJ et al., 1998).

a number of criteria that must be considered. Firstly, it must
be a real, sustained increase, that is, greater than the rate
of inflation. Ad valorem taxes such as the GST will increase

with actual prices. Secondly, the impact of the tobacco tax
will depend on the magnitude of the price increase. Thirdly,

it must be understood that smokers exhibit compensating

behaviour, for example, substituting with higher tar and
nicotine cigarettes. And finally, smuggling can reduce the
effect on consumption of a tax increase (Chaloupka, 1998),

as can other means of excise avoidance.

In Australia, a country without land borders, distant from
other producers of the types of cigarettes that smok­

ers want, smuggling is not believed to be a major issue.
Of greater local concern, is the increased use of roughly

chopped leaf, sold on the black market and sourced ille­

gally from the small number of remaining tobacco-grow­
ing areas in the country. This product appears to be used

mainly by the very poor.

Cigarettes and manufactured tobacco in Australia are sold,
broadly speaking, in two market sectors. Firstly, they are

sold from a large number of convenience shops, where
smokers purchase cigarettes at close to or at the recom­
mended retail price. Second, they are sold from supermar­

kets or specialist tobacconists, where prices are well below

the recommended retail prices (Scollo et al., 2000).
Smoking prevalence in the Australian adult population

decreased from about 36% in 1974 (Hill D and Gray, 1982)
to 22% in 1998 (Wakefield et al., 1999), a decline of about

39%. Over that time tobacco consumption declined by
58%, from around 3287 grams per capita in 1974 to 1364
grams per capita in 1998. This decline was due both to

reductions in the average number of cigarettes consumed
and reductions in the amount of tobacco per cigarette

(Winstanley et al., 1995). Most of the latter effect and
some of the former has probably occurred without any real

reduction in the level of exposure to tobacco-related toxins.

In Australia, tobacco companies had dampened the effect
of tax rises on smokers. Taxes were based on weight of

tobacco, so by reducing the amount of tobacco per ciga­

rette, without reducing yields, price could be contained.

Furthermore, through packaging cigarettes (often the
lighter sticks) in larger budget packs additional economies

were made. This has meant that smokers have been able

to avoid much of the price increases that extra taxes should
have produced by moving to these budget cigarettes.

Australia has a federal system of government, consisting of
the federal Government and each of six state governments

and two territory governments. Federal taxes, in the form
of excise or customs duty, had been levied on tobacco

based on the weight of the product since 1901. State­
based taxes, in the form of franchise fees—based on the

wholesale value of a pack of cigarettes—were only intro­
duced by the state of Victoria in 1974, originally calculated
at 2.4% of the wholesale price. Over the following couple

This report examines health groups' contribution to the

of years, each of the other five states and two territories

argument that the tax reform campaign should be used

introduced similar fees.

to secure reform of tobacco taxes in Australia. Such taxes

0

World Health Organization

Over the 25-year period described above, there were two

for both increases in excise duty and a change in the way

phases of marked increases in tobacco taxes. The first,

that excise duty was raised. No changes in the manner of

beginning in the 1980s, involved a 12-year period of

raising the excise were made at this time.

progressive leap-frogging of state-based tobacco licence
fees. For several years after they were introduced in 1975,

these fees remained at around 10% of the wholesale price

of cigarettes in most Australian states. Between 1981 and

Beyond the bi-annual indexation, there were no further
increases in Australian tobacco taxes between mid-1997
and late 1999.

1993, in response to budgetary pressures and capitalizing

Several countries such as Malaysia, Singapore and Sri

on the support of nongovernment health groups, various

Lanka tax tobacco products on the basis of weight, and

state and territory governments at various times increased

most countries impose ad valorem fees. However, in the

the fees in a series of steps to 75% (in most states).

25 years up to 1999, Australia was the only country in the

Between 1995 and 1997 there were also further increases

world to both impose ad valorem fees and to tax cigarettes

in state tobacco licence fees—from 75% to 100% of the

on the basis of weight rather than number of sticks (Scollo,

wholesale price. None of the additional revenue raised was

1996). The combination of the increasing ad valorem

invested in tobacco control programmes.

component of the overall tax structure combined with

In 1997, state tobacco licence fees were deemed by the

Australian High Court to be operating as an excise and as
such in breach of the Australian constitution. A key factor

in the Court’s finding was the lack of a clear relationship
between the level of the fees and the cost of regulating

tobacco control. The federal Government stepped in to
increase federal excise duty on tobacco products by an

amount equivalent to the abolished state fees, and to

return the resulting additional revenue to the states up

until 2000. Figure 1 shows the value of franchise fees
(or equivalent in 1998-1999) per average cigarette pack

the weight-based excise system resulted in lighter-weight,

bulk-packaged budget cigarettes rising in price substantial­

ly less than heavier, larger-diameter, premium brand ciga­

rettes. Each time franchise fees rose, manufacturers devel­
oped a lighter cigarette variant packaged in an ever-greater

pack size configuration (Figure 3). In this way, manufactur­

ers were able to offset, at least partially, the impact of the

steep increases in state fees. Australia became the only
country in the world where cigarettes were commonly sold

in packs of 30 or more—over 60% of smokers were pur­

chasing cigarettes in packs of 30, 35, 40 or 50.

in the largest Australian state New South Wales (NSW),

After the publication in 1990 of an Offices of Prices report

adjusted for inflation.

which, for the first time, highlighted the problem of large

Federal taxes, by contrast, remained pegged to inflation
between 1983 and 1993. A period of sharp excise increas­

es commenced in 1993 (Figure 2). This included small
increases in 1993 and 1994 a 10% increase in the 1995

budget. Major health groups had made submissions calling

Figure 1

pack sizes (Herington, 1990), health groups began advo­

cating for the levying of excise per stick. Both adult and
teenage smokers preferring large pack sizes smoked sub­
stantially more per week, in terms of both the number of
cigarettes smoked per day (Hill DJ et al., 1998) and the

Taxation reform as a component of tobacco control policy in Australia

Figure 2
Federal excise duty in Australia, Feb 1958 to 1999, converted to USS 89-90

overall weight of tobacco consumed (Scollo, 1996). Health

products. While several increases in excise were included

groups believed that large packs were encouraging the

in annual budgets over that time, there was little interest

development of more addictive patterns of smoking and
were providing price-sensitive smokers with an alternative
to quitting, thereby reducing the effectiveness of tobacco

excise increases as a'means of discouraging tobacco con­
sumption in Australia (Scollo, 1996).

The lobbying process

in addressing problems with the system.
To capitalize on the 1998 national tax reform campaign

announced by the then-Liberal Government, the Anti­
Cancer Council of Victoria contracted a consultant to

produce a more detailed and better-illustrated submission
(Scollo, 1998). The consultant was also to present this to

a consultative committee that had been established by

Between 1992 and May 1998, health groups had submit­

the Government to hear submissions from community

ted to the Government written proposals making the case

and business groups (Scollo, 1998). The National Heart

for increases and changes in the system of taxing tobacco

Foundation and the Australian Cancer Society also Support­

Figure 3
Price per stick of top-selling cigarette brands in Australia, USS 89-90

World Health Organization

ed the submission's author to accompany lobby group ASH

Description of policy intervention

Australia on several trips to the national capital in order to

explain the proposal and build support for its adoption.
Health groups made three basic requests:

- Replace current taxes with a simple cents per stick
system to remove incentives to market in larger packs;

- Consider excise increases as a means of financing
other elements of tax reform;

- Ensure that cigarettes do not become affordable in

the shift to a GST;

The submission of the nongovernmental organiza­
tions (NGOs) was successful in influencing the then-

Govemment. Prior to the 1998 Federal election (Costello,

1998), the Liberal Party released its major policy document
on tax reform. In it the Liberal PartyADDIN announced

that, if re-elected, it would replace the anomalous system

of taxes that had developed in Australia with a per stick
tax as advocated by health groups, at a level such that the

price of no cigarette brand would fall. The goods and serv­

- add GST without adjusting excise; and

ices tax was to be added on top of the new excise level.

- index wages and pensions with the Consumer

After it was re-elected, the Government released plans for

Price Index (CPI) excluding tobacco.

It was argued that the shift to a per stick system would

implementation of the policy (McCullough, 1999).

The new excise duty became operational on 1 November

lead to sharp increases in the price of larger pack formats

1999 (Costello, 2000), and was set at a level such that

and, in response, an immediate reduction in consumption

the tax component and price of premium packs of 20 or

among smokers continuing to use larger pack sizes. More

25 cigarettes rose slightly. As planned, the total tax pay­

importantly, it was predicted that, in the longer term,

able on large budget packs rose by more than 20%. This

fewer people would regularly smoke large packs, and

resulted in marked increases in prices for budget brands,

that this would also reduce the prevalence of very heavy

particularly those that used less tobacco, had lower diam­

smoking. Finally, it was hoped that the lower prevalence

eter tubes or were sold in large packages (40s and 50s)

of heavy smoking would translate, eventually, to higher

or both. Smoking (RYO) tobacco, cigars and cigarettes

population quit rates.

weighing more than 0.8 grams remained taxed by weight.

Traditional lobbying included letters and personal visits to:

- cabinet and shadow cabinet ministers;
- party whips, key power-brokers;
- health and economic policy committees for both
major parties; and

- treasurer and Prime Minister's advisers on tax
reform.
Additional, less formal input was provided by:

- briefing key academic economists from whom the

Government was seeking advice;
- meeting with and writing to members of a treasury

Eight months later, a GST of 10% was introduced on all
goods and services sold in Australia, and, as promised,

the Government applied the GST on tobacco product

sales without decreasing the excise. This resulted in price
increases somewhat lower that the 10% tax as manufac­

turers were required to pass on savings from tax reforms
that reduced cost in other parts of the production cycle.
Another major policy intervention was also operat­

ing in Australia prior to and during the introduction of

these reforms in tobacco taxation. The National Tobacco
Campaign (NTC), a major mass-media led campaign
launched in May 1997, had a very strong presence until
November 1997, and continued at a reduced level over

(departmental) Tax Reform Working Group;

the following four years. The Campaign featured a series

- approaching the treasurer at a party fund-raising

of hard-hitting advertisements (Hill, D et al., 1998) and

function;
- meeting with the presidents of political parties - at a

meeting at the Cancer Council; and

provided support to smokers via operation of a Quit line

and provision of resources to health professionals. The
campaign was associated with a marked reduction in
smoking prevalence in its first phase (to November 1997)

- briefing media spokespeople for the Business

Coalition; the Business Forum, a coalition of business
welfare groups; and the Tax Reform Commission, a
progressive group of economists and welfare groups.

6

(Wakefield et al., 1999). Therefore, when considering the
implementation of the tax reforms, it is important to look

at the potential effects of the NTC.

Taxation reform as a component of tobacco control policy in Australia

The impact of the intervention

of smokers to determine the dose, we suspect that this
resulted in little extra exposure to tobacco toxins per ciga­

This section provides preliminary information on the

rette smoked, but we cannot be certain.

impact of tax changes on recommended and actual retail

prices. It also documents changes in smoker consumption

The impact of reforms on prices at the retail

patterns over the period before and after the tax reforms

level

were implemented.

As intended, the shift to a per-stick method of levying

As part of the overall strategy to evaluate the NTC

excise duty in November 1999 resulted in a significantly

(described above), extensive data were collected through an

greater increase in the recommended retail price of budget

ongoing retail survey of cigarette prices (Scollo et al. 2000)

brands compared to premium brands (18% for budget

and an annual population survey. The population survey

brands, compared with only 5% for premium brands).

assessed brand preferences, prices paid, and reported daily

The differential between premium and budget brands (the

consumption and quitting attempts among 18- to 40-year-

percentage by which budget brands were cheaper than

old smokers, the main target of the campaign (Wakefield

premium brands) consequently reduced from a high of

et al. 1999). Data are presented from the first phase of the

25% in November 1995 to 12% following the change to

campaign, which lasted from May to November 1997

the per stick method. Further increases in cigarette prices

(Hill, D and Alcock 1999) and the third phase, which was

across the board were evident following the introduction

completed when data were collected in November 2000

of the GST in June 2000.

(Hill, D et al. 2000). A more detailed analysis can be found

Actual monitored retail prices were lower than recom­

in Scollo et al., 2003 (Scollo et al. in press).
The impact of reforms on the range of

tobacco products sold in Australia

Prior to 1999, cigarette brands could be split into three
reasonably clear segments: premium, value and budget
(Nicholas and Oldham 1998). Premium brands include

Marlboro, Benson and Hedges and other leading interna­
tional brands. Value brands included Peter Jackson 30s and
Escort 35s, which were launched in the 1970s in response
to the steadily increasing ad valorem state franchise fees.

The budget segment includes brands such as Holiday and
Horizon, which were first introduced in 1990 in packs of

50. In 1997 the premium segment had 35% of the mar­
ket, the value segment 35% and the budget section 25%,
with the rest spread among rare brands and RYO.

Between November 1997 (before the excise changes) and
November 2000 (a year after the excise change and four
months after the imposition of the GST), there was a 37%

increase in the number of pack variants, 84% of this in

smaller pack sizes (20s and 25s). This was in contrast to a
small decline in the total number of variants in the previ­
ous three years.

mended prices both before and after the reforms, and were
substantially lower in discount outlets. Actual monitored

retail prices increased in both the discount and convenience

sector for all segments of the market over the period of the

campaign. Recommended retail prices rose in parallel.
Between May 1997 and November 2000, average

(unweighted) recommended retail cigarette prices increased
by 34% and actual prices paid by smokers also increased
by 34%. Actual prices paid in each market segment

increased in line with recommended retail prices for each

brand segment (28 % compared with 27.6% in the premi­
um sector; 35% compared with 34% in the value segment,

and 40.1 % compared with 42% in the budget segment).
Reliable data are not available on the actual and reported

prices paid on roll-your-own tobacco, however extensive

data were collected in each NTC survey on what people
reported paying for factory-made cigarettes. Prices paid

for cigarettes increased in all brand segments and were
roughly equal across socioeconomic status groups. The

same pattern of increase was observed with the discount and
convenience sectors, and for pack and carton purchasers.
Smokers' attempts to offset the impact of

Following the introduction of the per stick system, all

price increases

three tobacco companies reconfigured a number of the

The proportion of smokers favouring budget brands

most popular cigarette brands, increasing the amount of

declined significantly between 1997 (17%) and 2000

tobacco in each cigarette and promoting the reconfigured

(10%), with all the change being to premium brands.

brands as "better value for money". Given the tendency

Once again this trend applied to both blue- and white-col­

0

World Health Organization

lar groups, for carton as well as for pack purchasers, and

Consistent with these observed trends, 52% of smokers

for purchasers in both the discount and the convenience

reported in November 2000 that they found cigarettes

sector. Some of this occurred before the excise changes.

Following the shift to the per stick excise system in
November 1999, there was a substantial reduction in

the percentage of remaining smokers using 40s and 50s
(down from 30% to 19%). There was also a correspond­

"more difficult to afford compared with one year ago".
Overall, around 11 % of smokers reported changing to

RYO (4%) or a cheaper brand (7%), and 13% reported
that they smoked fewer cigarettes.

Changes in cigarette consumption

ing increase in the proportion of remaining smokers using

20s and 25s (up from 48% to 58%).

Changes in consumption can be due to quitting or to

The rise in prices may have increased supermarket sales at

Analysis of data from the NTC Evaluation respondent sur­

the expense of other places, but the effect is small. There

veys indicates a significant drop in consumption among

reduced consumption among remaining smokers or both.

was a continuing shift to RYO cigarettes, which may relate

remaining smokers over the period of the campaign. This

to greater use of illicit tobacco known as Chop-chop,

occurred both among blue- and white-collar groups.

which is grown and clandestinely distributed by farmers

During the period of high advertising and small price

and wholesalers and sold without government intervention

changes there was little change in consumption per smok­

or taxation. There was no significant change in the propor­

er (-.65%), while following the price rises the reduction

tion of remaining smokers buying cartons over the course

was greater (-7.84%). This seems to have led to a reduc­

of the campaign (Table 1).

tion in the percentage of heavy smokers (25+ per day).

Apart from the shift to RYO and a shift to discount outlets

As anticipated, average consumption among remaining

during Phase 1 of the campaign, it appears that remain­

smokers using larger pack sizes appeared to reduce more

ing smokers have not been able to cushion themselves

significantly than consumption among smokers using

from the impact of cigarette price increases by shifting to

smaller pack sizes (Table 2). The reduction in consumption

cheaper brands, format and outlets. In fact, as intended by

due to the price increases remained significant (p<.05)

the November 1999 cigarette excise reforms, which differ­

after taking account of the change in cost/stick, and any

entially increased the price of light-weight cigarettes, there

sex, age, education, and socioeconomic status differences.

has been a large shift away from budget brands and large
To assess the likely contribution to reduced tobacco use of

pack sizes.

cigarette price increases, it is first of all necessary to estab­
The extent to which the decline in the percentage of

lish how much less affordable cigarettes were in November

smokers using budget brands results from differential rates

2000 compared to November 1998 before the tax reforms,

of quitting among budget versus premium smokers or a

and May 1997 at the commencement of the NTC.

real shift among remaining smokers to smaller pack sizes is
unclear. However, the size of the effect suggests much is

Average per stick prices paid by smokers were adjusted
for each phase of the campaign to take account of overall

due to brand shifting.

Table 1. Summary of changes in prevalence of price-minimizing behaviours_____________________
Benchmark

Follow-up 2

Follow-up 4

% change

% change

May 1997

Nov 1998

Nov 2000

May 97 to

Nov 98 to

(n=921)

(n=1239)

(n=1155)

Nov 1998

Nov 2000

% using RYO

13%

17%

22%

+31 %

+29%

% using budget brands

17%

14%

10%

-18%

-28%

% using 35s, 40s or 50s

29%

32%

21%

+10%

-34%

% using discount outlets

48%

55%

54%

+15%

-2%

% using cartons

14%

13%

12%

-7%

-8%

At least weekly

smokers

Source: NTC Evaluation respondent surveys

Taxation reform as a component of tobacco control policy in Australia

Table 2. Reported cigarette consumption among current smokers, by pack size

Benchmark,

Follow-up 2 -

Follow-up 4 -

May 1997

Nov 1998

Nov 2000

For daily and weekly smokers

n=1,075)

(n=1,496)

(n=1,480)

Mean cigs/day (sd)

15.4 (10.4)

15.3 (10.3)

14.1 (9.4)

At least weekly smokers

Pack size 20

10.5(7.4)

9.9(7.9)

9.8 (7.6)

Pack size 25

13.2(10.0)

12.8(8.3)

13.1(9.8)

Pack size 30

15.0(9.2)

15.5(10.4)

15.1(9.1)

Pack size 35

17.8(10.5)

18.0(10.7)

14.2(5.8)

Pack size 40

18.1(9.8)

20.2(9.6)

17.4(8.7)

Pack size 50

22.3(11.4)

19.2(10.3)

18.4(9.3)

Source: NTC Evaluation respondent surveys

increases in prices of common consumer goods and serv­

can be compared with observed reductions of 5.4% and

ices since the previous phase (Table 3). This shows that the

4.3% respectively. Price cannot explain the drop in the

excise changes did lead to greater real changes.

first phase of the NTC, but it can explain the drop in the

subsequent phase, which corresponded with the excise
International research suggests that the price sensitivity

reforms. The drop in the first phase seems to be in part

of demand for cigarettes in Western countries is probably

due to the strong advertising campaign. For consumption,

around -0.4 (Centers for Disease Control and Prevention,

the picture is somewhat different. We estimate reductions

1998). That is, for every 10% increase in cigarette prices,

of 0.7% and 2.8% respectively and found reductions of

cigarette consumption can be expected to fall by about

0.7% and 7.8%. Here price can account for the reduc­

4%. There is also evidence from behavioural studies, how­

tion in consumption in the NTC period, but underesti­

ever, that price sensitivity of demand may be higher where

mates consumption declines in the excise reform period.

prices are higher. (Bickel etal., 1990). Australian cigarette

Sensitivity analysis for this is found in Table 4.

prices are among the highest in the world (Scollo, 1996).

Separate estimates were derived for the impact on smoking

The higher-than-expected effects of the excise reforms

participation and consumption among remaining smokers.

on consumption could be due to the reduced opportunity

International research has indicated that around three-fifths

to compensate. We also need to consider other potential

of the drop in demand tends to be due to reduced smoking

contributions such as the role of nicotine replacement

prevalence, and around two-fifths to reduced consumption

therapies, which became more widely promoted and more

by remaining smokers (Chaloupka, 1998).

readily available in Australia over this time. This was also a

How do these estimates compare with overall changes in

acceptability of smoking indoors, even in the home and

smoking participation and prevalence over the period of

this may have acted to drive down consumption as well.

period of rapid change in social norms with regard to the

the NTC? Data from NTC Evaluation surveys indicate that
the proportion of the population aged 18 to 40 years who

smoked fell by about 9.5% over the period of the NTC,

with just over 4% of the reduction occurring in the last two

years of the Campaign following tax changes. A roughly
equal drop in participation occurred among blue- and

Other effects
Source: Industry data provided to Australian members of

Parliament, updated with excise data from ABS

white-collar groups, with most of the drop among bluecollar groups occurring in the third stage of the campaign

Industry reports suggest that production figures reduced
significantly in response to price changes. Figure 4 shows

In short, if we assume a sensitivity of demand for both
participation and consumption of 0.4 we would expect
a reduction in participation of about 1 % over the NTC

period and 4.3% over the excise reform period. This

that there was a decline in production leading up to the

changes, and further declines thereafter. The figures for
June 2000 suggest that the industry may have underesti­

mated the likely effect and overproduced in the short term.

World Health Organization

Summary

Despite some evidence of a shift to roll-your-own tobacco,
the reforms appear to have contributed to the recent

Recent tobacco tax reforms do seem to have been effec­

decline in smoking participation in Australia, and in par­

tive both in increasing the availability of smaller pack size

ticular to a decline in heavy smoking and in reported

configurations for popular brands and in reducing the

consumption among remaining smokers, particularly those

affordability of factory-made cigarettes, particularly the so-

using budget cigarette brands. The decline in cigarette

called budget brands.

consumption and smoking participation appears to have
occurred across all socioeconomic groups.

Table 3. Summary of changes in affordability of cigarettes and expected total consumption

changes over the period of the NTC
Benchmark
May 1997
(n=921)

Follow-up 2
Nov 1998
(n=1239)

Follow-up 4
Nov 2000
(n=1155)

% change
May 97 to
Nov 2000

% change
Nov 98 to
Nov 2000

per cigarette -

(n=881)

(n=1T71)

(n=1053)

5.8%

26.8%

cents per stick

22.60

23.90

30.30

CPI for relevant

120.2

121.9

131.3

1.4%

7.7%

22.60

23.57

27.74

4.4%

17.7%

At least weekly
smokers
Benchmark

Average price paid

quarters
Average price paid
per cigarette in

AUS$ May 1997
Source: NTC Evaluation respondent surveys; Australian Bureau of
Statistics, Consumer Price Index (ABS 2001)

Table 4. Expected compared to actual falls in smoking prevalence and consumption among

_______________________________

respondent groups
Period

May 1997 to Nov 1998

Nov 1998 to Nov 2000

4.4%

17.7%

Price increase

Expected fall @
price demand
elasticity

Consumption

Prevalence

Consumption

Prevalence

-0.3

- 0.65%

-0. 65%

-2.65%

-2.65%

- 0.5

- 1.08%

- 1.08%

- 4.23%

-4.23%

- 0.7

-1.51 %

-1.51%

-6.20%

-6.20%

Actual falls

-5.42%

- 0.65%

- 4.30%

- 7.84%

Prevalence

Consumption

Prevalence

Consumption

@ - 0.3

12%

100%

62%

34%

@ - 0.5

20%

166%

98%

54%

28%

232%

144%

79%

Percent of
reduction
plausibly
explained by
price increases

@ - 0.7

Source: NTC Evaluation respondent surveys; Australian Bureau of
Statistics, Consumer Price Index [10]; Centres for Disease Control
MMMW bulletins [11]

Taxation reform as a component of tobacco control policy in Australia

References

Scollo M (1996) Closing the Loophole-The Need for Action in
1997. Melbourne, Anti-Cancer Council of Australia: 28.

ABS (2001) Consumer Price Index, 6401.0. Canberra, Australian
Bureau of Statistics.

Scollo M (1998). Federal Excise Duty on Tobacco - Proposals for
Reform. Melbourne, Anti-Cancer Council of Victoria.

Bickel W et al. (1990) Behavioural economics of drug self-admin­

istration. Functional equivalence of response requirement and
drug dose. Life Science, 47: 501-510.

Scollo M, Freeman JMW (in press) Early evidence of impact of

recent reforms t tobacco taxes on tobacco prices and tobacco
use in Australia. National Tobacco Campaign Evaluation

Centers for Disease Control and Prevention (1998) Response to

Volume No. 3. Canberra, Department of Health and Ageing. 3.

Increases in cigarette prices by race/ethnicity, income and

age groups - US, 1976 -1993. Morbidity and Mortality
Weekly Report, 47.

Scollo M, Owen T, Boulter J (2000) Price discounting of cigarettes
during the National Tobacco Campaign. Australia's National

Tobacco Campaign. Evaluation Report Volume Two. Hassard
Chaloupka F (1998) How Effective are Taxes in Reducing Tobacco

Consumption. The Social Cost of Smoking, Lausanne,

K, Canberra, Commonwealth Department of Health and

Aged Care, 155-200.

Switzerland.

Costello P (1998) Not a new tax: a new tax system. Canberra,
Australian Government Printing Service.

Wakefield M, Freeman J, Boulter J (1999) Changes associated
with the National Tobacco Campaign: pre and post campaign

surveys compared. Australia's National Tobacco Campaign.

Costello P (2000) Excise Tariff Amendment Bill (No. 1),
Explanatory Memorandum. Canberra, The Parliament of the

Evaluation Report Volume One. Hassard K, Canberra,
Commonwealth Department of Health and Aged Care.

Commonwealth of Australia, House of Representatives.

Winstanley M, Woodward S, Walker N (1995) Tobacco in
Herington A (1990) Does Smoking Make Cents? Melbourne,
Victorian Office of Prices.

Australia; facts and issues 1995, Carlton South, Victorian

Smoking and Health Programme.

Hill D, Alcock J (1999). Background to campaign. In: Hassard

K (ed.) Australia’s National Tobacco Campaign: Evaluation
Report Volume One. Canberra, Commonwealth Department

of Health and Aged Care.

Hill D et al. (2000) Perspectives of the Australian National Tobacco
Campaign. Australia's National Tobacco Campaign, Evaluation
Volume Two. Hassard K. Canberra. Commonwealth

Department of Health and Aged Care: p. 1-9.

Hill D, Gray N (1982) Patterns of tobacco smoking in Australia.
Medical Journal of Australia, 23-25.

Hill D, Donovan, R (1998) The return of scare tactics. Tobacco
Control, 7: 5-8.

Hill DJ, White VM, Scollo M (1998) Smoking behaviours of

Australian adults in 1995: trends and concerns. Medical
Journal of Australia, 168: 209-213.

McCullough P (1999). Media release: Reform of Tobacco

Taxation, Australian Treasury.
Nicholas D, Oldham D (1998). Australian Tobacco. Breathe Easy.

Melbourne, Merrill Lynch, Global Securities Research and
Economics Group.

Scollo M (1996) The Big Mac index of cigarette affordability.

Tobacco Control, 5: 69.

11

Labelling and Packaging
(including Health
Warrant’2}

Thailand Country Report
on Labelling and Packaging

who/t™™’2

pH'r"

Thailand: Country Report
on Labelling and Packaging
Hatai Chitanondh
M.D., F. I. C. S., F. R. C. S. (T)

President
Thailand Health Promotion Institute

World Health Organization

World Health Organization

4
Tobacco Free Initiative Headquarters would like to thank the Regional Offices
for their contribution to this project.

WHO Regional Office for Africa (AFRO)
Cite du Djoue

Bolte postale 6

WHO Regional Office for Europe (EURO)

8, Scherfigsvej
DK-2100 Copenhagen

Brazzaville

Denmark

Congo
Telephone: +(1-321) 95 39 100/+242 839100

Telephone: +(45) 39 17 17 17

WHO Regional Office for South-East Asia (SEARO)
WHO Regional Office for the Americas / Pan

American Health Organization (AMRO/PAHO)

World Health House, Indraprastha Estate
Mahatma Gandhi Road

525, 23rd Street, N.W.

New Delhi 110002

Washington, DC 20037

India

U.S.A.

Telephone: +(91) 11 337 0804 or 11 337 8805

Telephone: +1 (202) 974-3000
WHO Regional Office for the Western Pacific
WHO Regional Office for the Eastern

(WPRO)

Mediterranean (EMRO)
P.O. Box 2932
WHO Post Office

Abdul Razzak Al Sanhouri Street, (opposite Children's

Library)
Nasr City, Cairo 11371

Egypt
Telephone: +202 670 2535

2

1000 Manila
Philippines
Telephone: (00632) 528.80.01

Thailand: Country Report on Labelling and Packaging

introduction
From 1981 to 2001 there were dramatic changes in tobac­
co consumption in Thailand. The total number of smokers
rose from 9.7 million in 1981 to 10.6 million two decades

0

Table 1
Estimated number of deaths from diseases in
South East Asia, 2001

Diseases

Deaths

during the same period. The male smoking rate decreased

Cancer of trachea, lung, and bronchus

35 000

from 63.2% to 42.9%, while female prevalence fell from

Cancer of mouth and oropharynx

16 000

later. Smoking prevalence declined from 35.2% to 22.5%

5.4% to 2.4.%. Per capita consumption rose from about
774 in 1970 to 1 087 in 1980. Since that time, it has

Respiratory diseases

130 000

decreased progressively to 798 in 2000.

Ischaemic heart diseases

232 000

Figure 1
Per capita consumption estimates 1970-2000

Source: World Health Report, 2002. Geneva, World Health
Organization, 2002.

In terms of cancer of the various organs, lung cancer was
the second most common cancer between 1988 and 1991

in Thailand. Women in the northern region of the coun­

try, who have the highest smoking prevalence among the
various regions, have lung cancer at an age-standardized
incidence rate of 37.4 per 100 000 (1).

Policy intervention
Policy intervention on labelling and packaging, including

health warnings, only involves manufactured cigarettes.

This applies equally to both domestic and imported ciga­
rettes. Other tobacco products, e.g. cigars and pipe tobac­
Source: Developed by THPI from: Guidon GE, Boisdair D. Past,
Current and Future Trends in Tobacco Use.
HNP Discussion Paper.
Economics of Tobacco Control, Paper N° 6, February 2003.

co, are not included because there are too many varieties
of packages and it is difficult to carry out regulatory proce­
dures. In addition, the consumption level of these products

is low and small gains in health are not worth the regula­
There have been no systematic studies of morbidity and

tory effort.

mortality of tobacco-related diseases. Table 1 shows that

In Thailand, policy is based on legislative action. Initially,

the estimated number of deaths from various diseases in

the Medical Association of Thailand pressed for regula­

South East Asia for 2001 (within the low child and low

tory action and such issues were later taken up by the

adult mortality stratum to which Thailand belongs).

Announcement of Labelling Committee of the Consumers
Protection Board (CPB) pursuant to the Consumers
Protection Act 1979. This announcement became effec­

tive on 20 September 1990. Finally, labelling was man­
dated by successive Ministerial Announcements pursuant

to the Tobacco Products Control Act (TPCA) 1992. After

this Act became effective on 3 August 1992, the CPB's
Announcement of Labelling Committee was disbanded.
These efforts are outlined chronologically in table 2.

3

World Health Organization

Steps toward implementation
Before 1989 there was no established national policy to

control tobacco consumption. In late 1988, the Deputy
Director-General of the Department of Medical Services

(DMS), proposed and received approval from the thenMinister of Public Health (later a two-time Prime Minister

of Thailand) to establish an inter-agency policy commit­

and Prime Minister’s office; Deputy Permanent Secretary
for Health of the Bangkok Metropolitan Administration;

Director-Generals of Departments of Health, Medical
Services, Excise, Public Relations; President of the
Reporters Association of Thailand, Secretary-General

of the Medical Council, and five experts. The DeputyDirector-General was the NCCTU's first secretary.

The Ministry of Public Health (MOPH) proposed the for­

tee for tobacco control called the National Committee for

mation of the NCCTU. The proposal received approval

Control of Tobacco Use (NCCTU).

from the Cabinet and the Committee was formally estab­

In the proposal the committee appointed the Public Health

lished on 14 March 1989. This interagency body is now

Minister as the chairman. The members comprised chair­

responsible for formulating the country’s policy on tobacco

persons of the standing committee on health of both

control. To this end it has initiated several tobacco control

the Senate and the House of Representatives. They were

policies, one of which was a regulation mandating health

the following: permanent secretaries1 of the Ministries of

warnings.

Public Health, Education, Agriculture, Interior, Finance,

Table 2
Chronology of regulation on labelling and packaging

The first health warning
1967

A secretary-general of the Medical Association of Thailand under Royal Patronage, who was also a chest
physician with post-graduate training in the United States of America, requested that the Ministry of
Finance require the Thailand Tobacco Monopoly (TTM) to print a health warning on cigarette packages

they produced. (The Ministry supervises the TTM, which was the only cigarette manufacturer in the coun­

try at that time).
1974

After a long delay, the TTM began printing the small health warning 'Smoking may be harmful to health'

on the side of cigarette packages.
The second set of health warnings
25 April

At its first meeting the NCCTU secretary proposed that there had been only one small health warn­

1989

ing placed on cigarette packets and six new rotating health warnings should be mandated. The NCCTU

approved the new set, which comprised the following messages: 'smoking causes lung cancer and emphy­
sema', 'smoking causes ischaemic heart disease', 'smoking harms babies in the womb', 'respect other peo­
ple’s rights by not smoking in public places', 'giving up smoking reduces serious illness' and ‘for the sake
of your children please give up smoking'.

1989

The cabinet endorsed the MOPH proposal mandating health warnings on cigarette packages and ordered
the CPB to take further action.

18 May

The CPB's Labelling Committee mandated a seventh health warning on cigarette packages, namely,

1990

‘smoking may be harmful to health' (this warning had been in place since 1974), as well as the six warn­

11 July

ings approved by the cabinet. These had to be placed in the front of the package, the size of the letters
had to be at least 1 mm wide and at least 2 mm high. The warning had to be evenly distributed among
the produced packages. This announcement became effective on 20 September 1990.

The procedures for enacting a law or a regulation pursuant to a certain section of a law must follow these
consecutive steps:

Thailand: Country Report on Labelling and Packaging

— a law is passed by the National Assembly;

— the Prime Minister proposes the law to His Majesty the King of Thailand;

— the King signs on to the law and returns it to the Prime Minister, who counter signs; and
— a regulation or ministerial announcement is sent to the Government printing house to be published
in the Royal Gazette. The announcement is publicized by the person responsible for that law, and

includes a statement on how many days following its publication the law will become effective.

The third set of health warnings

3 August
1992

The TPCA 1992 was enacted and became effective as of 3 August 1992. Section 12 of this Act stated that
'the manufacturer or importer of the tobacco products must place the labels on the packages of tobacco
products before they leave the manufacturing site or before importation into the Kingdom2 as the case

may be.

The criteria, procedures and conditions of displaying these labels and the statements therein shall be in
accordance with those published in the Government Gazette by the Minister.3

25

Following a meeting of the NCCTU, it was decided that a new set of health warnings would be mandated.

August

The Ministerial Announcement, pursuant to Section 12 of the TPCA 1992, was issued mandating ten

1992

rotating health warnings on cigarette packages. They were the following: 'smoking causes lung cancer',

‘smoking causes heart disease", 'smoking causes lung emphysema', ‘smoking causes obstructive or haem­
orrhagic stroke', ‘smoking kills', 'smoking is addictive', ’smoking is harmful to people around you’, 'smok­

ing is harmful to babies in the womb", 'quitting smoking reduces the risk of serious illness’ and 'giving up
smoking leads to a healthy body'.

The warnings had to occupy no less than 25% of the front and back of the main surfaces of cigarette
packages or cartons. The lines bordering the warnings had to be white and letters black. The size of the

font 'Si Phya’ had to be 16 points for packages that have 37 cm2 of the main surfaces, 21 points for 37-

85 cm2, 33 points for 85 cm2 and 36 points for the cartons.

24 Sept.

1992

The announcement was published in the Royal Gazette and the regulation became effective one year
later.

This set of warnings represented a significant strengthening of tobacco control laws compared to previous
ones. This was largely due to the fact that MOPH had just passed its own law (the TPCA 1992), which

was a means of putting its regulations into effect. In addition, the Ministry had just established the first
national governmental agency for tobacco control - the Office of Tobacco Consumption Control, which
acts as a full-time secretariat for the NCCTU. The first and second set of health warnings were initiated by
other mechanisms outside the full control of the MOPH, that is, by the Medical Association of Thailand

under Royal Patronage and by the NCCTU via the Consumers Protection Act, which fell under the respon­

sibility of the CPB of the Prime Minister's Office. The third version was achieved by the NCCTU secre­
tariat.
1 A permanent secretary is the highest ranking permanent
official of a ministry.
2 "Kingdom" is the legal term for the Kingdom of Thailand

3 "Ministers" means the Minister of Public Health who is
responsible for this Act.

5

World Health Organization

The fourth set of health warnings

15
October

1997

____________ ______________________________

The NCCTU decided to mandate a new version of health warnings. The new Ministerial Announcement
was issued replacing the former one, mandating ten health warnings on cigarette packages: 'smoking
causes lung cancer', 'smoking causes heart failure', ‘smoking causes emphysema , smoking causes brain

haemorrhages, smoking causes leads to other addictions, 'smoking causes impotence', 'smoking causes
premature aging', 'smoking can kill you', 'smoke harms people near you’, and 'smoke harms babies in the

womb'. The warnings had to follow the requirements described below.
— The warnings, including bordering lines, must occupy no less than one-third of the principal surfaces of
the cigarette packages or cartons.

— The border must be white and 2 millimetres thick.
— The background must be black and the letters white.
— The letter font must be 'Si Phya’ and the size must be 20 points for packages with an area of 37 cm2

front and back, 25 points for an area of 37-80 cm2, 38 points for 80+ cm2 areas and 75 points for
cigarette cartons.

4 Nov.

The announcement was published in the Royal Gazette and became effective one year later.

1997
The fifth set of health warnings - the pictograms
Feb.

The president of the Thailand Health Promotion Institute (THPI), who was a DMS adviser, suggested to

2000

the then-Director-General of the DMS that Thailand mandate pictorial health warnings. The Director-

23 March

The MOPH approved the DMS proposal and set up a committee to consider graphic health warnings on

2000

cigarette packages. The DMS Director-General was the chairman and THPI president was the vice-chair­

5 April

At the first meeting TTM representatives opposed the printing of graphic health warnings on cigarette

2000

packages. The THPI president, who was the meeting chairman, asked the TTM to submit an official letter

General agreed and ordered the DMS's Institute of Tobacco Consumption Control (ITCC) to proceed.

man.

explaining its reasoning. In its letter the TTM stated that they only had a printer that could produce threecolour pictures. For four-colour pictures a new machine would have to be imported, and in addition to
costing 12 million Baht, it would take two to three years to acquire.

The THPI president asked the ITCC to ignore the TTM's complaint and proceed to acquire three-colour
pictures for the health warnings.
The protracted delay in implementation could have been due to either the ITCC's bureaucracy or the

tobacco industry's underground lobbying. In Thailand the transnational tobacco companies never act
publicly because every time they do they are heavily challenged by the country's strong tobacco control

advocates.
28 Feb.

During the NCCTU meeting the THPI president complained that the process of acquiring pictorial health

2002

warnings was dragging and the NCCTU ordered further action without delay. New subcommittees were

established, one for implementation of the TPCA.
26 April
2002

At the subcommittee meeting chaired by the THPI president it was decided that 12 pictorial health warn­
ings would be put in the Ministerial Announcement. The themes of the 12 pictures included the 10 previ­
ous warnings and 2 new ones 'smoking causes oral cancer' and 'smoking causes foul odours and black­

ened teeth'.

6

Thailand: Country Report on Labelling and Packaging

3 May

After several contacts with the ITCC to determine the progress of preparing pictures and ministerial

2002

announcements, the THPI president found that there were certain obstacles in the process, namely, the

major difficulties in acquiring pictures through bureaucratic means. The THPI then decided to use media

advocacy to push for the policy's achievement by releasing a press message reporting that Philip Morris
had sent a letter dated 27 February to the Public Health Minister threatening to take legal action if the

MOPH ordered the printing of pictorial health warnings on cigarette packages.
4 May

The press release culminated in a continuous stream of news, letters, and articles in the media and in inter­

-17 June

national news agencies as well as numerous radio and television interviews, including CNN.

2002
11 May

2002

An entire week after news broke out of the Philip Morris threat the Public Health Minister stated in a press
interview that the MOPH did not believe that the decision mandating pictorial health warnings was con­

tradictory to the Constitution and TRIPS (Trade-related aspects of intellectual property rights), and that the
MOPH would go ahead with the plan.

17-21
June

2002

The THPI president asked for and received a green light from the DMS to produce the pictures. It was
decided that five pictures, which depicted diseased organs, would be acquired from hospital slide librar­
ies, that is, lung cancer, heart disease, emphysema, stroke, and oral cancer, and the other seven pic­

tures would be acquired by conducting a country-wide contest so that the public could participate. The
Photography Association of Thailand under Royal Patronage was invited to collaborate and the Thai

Health Promotion Foundation was asked to fund the contest.

3 July

Nongovernmental organizations (NGOs) organized the award ceremony for the contest winners. The

2002

Minister of Public Health was invited to chair the events.

6 Sept.

The THPI sent the complete set of pictorial health warnings to the DMS Director-General to draw up the

2002

ministerial announcement and proposal for the Minister of Public Health to sign.

1 Oct.

2002

The newly organized MOPH proposed that tobacco control work be a part of the new Department of
Disease Control (DDC).

1 Nov.

The THPI president sent a letter to the DDC Director-General urging him to expedite the long-delayed

2002

process.

20 Jan.

The DDC Director-General called a meeting to consider pictorial health warnings. THPI president and

2003

Action on Smoking and Health (ASH) Secretary-General were invited. The Director-General asserted that
the 12 pictures acquired did not seem to communicate very well to the viewers. The meeting decided to
have a pre-test for these pictures.
After acquiring satisfactory pictures there are still a few steps to be taken: drawing up the Ministerial

Announcement, sending a proposal to the MOPH Minister for signature; and publication in the Royal

Gazette. This regulation would become effective six months following its publication. The long interval
would provide ample time for the cigarette producers to clear their stock and produce the new labelling.

World Health Organization

Opponents counter the intervention

The tobacco industry does not want graphic health warn­

ings and would go to any lengths to obstruct this effort.
There are two main reasons:
— The pictograms were found to be very effective. An
evaluation in Canada showed that 44% of smokers

said the pictorial health warnings increased their moti­
vation to quit, 58% thought more about the health

effects of cigarettes, 27% were motivated to smoke

less inside their home, and 62% thought the picto­
grams make the packages look less attractive.

this right unnecessarily because existing health warn­
ings already cover one-third of the pack."
— Reality: The Government also has the right to clearly

inform the people about the health hazards of smoking.
— Myth 4: "Trademarks are valuable Company property

and are protected by the Trademark Act B.E. (Buddhist
Era) 2534, the Penal Code, as well as by TRIPS, of
which Thailand is a member. TRIPS provides that the
use of a trademark shall not be unjustifiably encum­

bered by special arrangements, such as use in a special

form or manner detrimental to its capacity to distin­
guish the goods or service of one undertaking from

— Thailand would be the third country in the world to

mandate graphic health warnings if the regulation

passes and it would be an exemplary regulation that
other countries would follow.

those of other undertakings. The Regulation would
violate this principle."

— Reality: The Trademark Act B.E.2534 prohibits destruc­
tion or imitation of trademarks. The pictograms would

The Philip Morris letter of 27 February 2002 was sent

do neither.

to the Public Health Minister, though no one knew her
response or that of her secretariat. The TH PI president

TRIPS provides public health exception in Article 8.2,

knew of the Philip Morris action from a DMS official and

which states that the "Member may, in formulation or

asked a DMS Deputy-Director-General to fax the Philip

amending their national laws and regulations, adopt meas­

Morris letter. The THPI then used the letter for advocacy

ures necessary to protect public health and nutrition, and

in the media to reinforce the policy of educating smokers

to promote the public interest in the sectors of socioeco­

through pictorial health warnings.

nomic and technological development, provided that such

measures are consistent with the provisions of this agree­
The Philip Morris letter propagated four myths.
— Myth 1: "It would impose an undue burden on the

ment." Therefore, the regulation on pictograms does not
violate TRIPS.

Company in that Ministerial Regulation (No.6). B.E.

2543 already requisitions 33.3% of the total area of a
cigarette pack for the prescribed textual health warn­

ings.”
— Reality: What type and how big is the 'undue bur­

den'?

The Philip Morris letter sent to the Public Health Minister
was meant only to bluff those who were unfamiliar with

Thailand's copyright law, its constitution and TRIPS. By
citing the risks involved in their taking legal action, the

tobacco multinationals had hoped that the MOPH bureau­
crats would stop the implementation process.

— Myth 2: "The Regulation would impair the use of
the Company's valuable trademarks by obscuring the

The intervention’s success

marks on the pack face, thereby undermining the

trademarks' functions of brand identification and com­

Regulation on packaging and labelling has been quite

munication with the Company's customers. Packaging

successful. To date, the first four different sets of health

is more important for cigarettes than other prod­

warnings have been mandated. The number of rotating

ucts since all forms of advertising are banned by the

warnings has increased from one to twelve. The warn­
ing area size on cigarette packages and cartons has been

Tobacco Products Control Act."

— Reality: The trademarks are still there and not
obscured.

— Myth 3: "The Company has the right to communicate
with its customers through its display of trademarks
and logos. Any attempt to limit this right must be

necessary to achieve a legitimate public purpose. The

imposition of the graphic health warnings would limit

enlarged from small letters on the sides of cigarette pack­

ages to one-third of the principal surfaces of packages,
including cartons. The last set of pictorial health warnings,
occupying half of the front and back, is being prepared
and it is hoped that it will be enacted in 2003.

Thailand: Country Report on Labelling and Packaging

In Thailand, there has been no scientific study of the

impact of cigarette package textual health warnings on
tobacco use.

Other impacts of the intervention
The graphic health warnings have created immense public
interest. There is widespread support from the media and

all sectors of society.

Media advocacy about pictorial health warnings has been
enormous as the following figures demonstrate:

— After the THPI press release, from 4 May to 17 June
2002, the subject was mentioned 16 times in the

newspapers and 6 of those articles were published on
front pages; 4 letters and 5 newspaper articles devoted
to the subject; at least 4 news releases by international
news agencies, including CNN, and innumerable radio

and television interviews.

— Before and after the picture contest described in Table 2,

from 17 June to 4 July 2002, pictorial health warnings
were mentioned 23 times in newspapers; there were 4

newspaper articles on the subject, 1 public opinion poll,
and numerous radio and television interviews.

Conclusion
Package labelling is a vital measure in controlling tobacco.

It should be mandated with minimum cost, changed
at appropriate intervals, and improved consistently.

Thailand's legal system enables it to be easily implemented
because packaging and labelling is a section of the law
and regulation can be passed pursuant to the legislation.
Textual health warnings can be changed and upgraded

into pictorial ones that have, according to the Canadian

experience, better impact upon smokers.

References
1. Vatanasapt V et al. Cancer Incidence in Thailand 1988-1991.
Cancer Epidemiological Biomarkers & Prevention 1995; 4(3):
127-138.

9

Advertising and
Promotion
Bans

Thailand Country Report on Tobacco Advertising
and Promotion Bans.

WHO/NMH/TFI/TFC/03.9

Thailand Country Report on Tobacco
Advertising and Promotion Bans
Hathai Chitanondh
President, Thailand Health Promotion Institute

World Health Organization

World Health Organization

Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

WHO Regional Office for Africa (AFRO)
Cite du Djoue

Bolte postale 6

WHO Regional Office for Europe (EURO)

8, Scherfigsvej
DK-2100 Copenhagen

Brazzaville

Denmark

Congo
Telephone: +(1-321) 95 39 100/+242 839100

Telephone: +(45) 39 17 17 17

A
WHO Regional Office for the Americas / Pan

WHO Regional Office for South-East Asia (SEARO)

American Health Organization (AMRO/PAHO)

World Health House, Indraprastha Estate
525. 23rd Street. N.W.

Washington, DC 20037

New Delhi 110002
India

Telephone: +1 (202) 974-3000

Telephone: +-(91) 11 337 0804 or 11 337 8805

WHO Regional Office for the Eastern

WHO Regional Office for the Western Pacific

Mediterranean (EMRO)

(WPRO)

WHO Post Office

Abdul Razzak Al Sanhouri Street, (opposite Children’s
Library)
Nasr Gty, Cairo 11371

2

Mahatma Gandhi Road

U.S.A.

Egypt
Telephone: +202 670 2535

P.O. Box 2932
1000 Manila

Philippines

Telephone; (00632) 528.80.01

Thailand Country Report on Tobacco Advertising and Promotion Bans

Introduction

For the past two decades, the total number of smokers has
risen, presumably as a result of the rise in population, from

Countrywide household surveys by the National Statistical

Office have been the main source of information support

for tobacco control in Thailand. The first, second and third

surveys were carried out in 1976, 1981 and 1986 (five
year intervals). Thereafter the surveys were carried out
every two years.

9 676 700 in 1981 to 10 551 300 in 2001. Smoking prev­

alence declined from 35.2% in 1981 to 22.5% in 2001.
Male and female smoking rates fell in this period from

63.19% to 42.92%, and from 5.39% to 2.36% respec­
tively. Annual adult per capita cigarette consumption has
also been decreasing, from 1087 in 1995 to 798 in 2000.

Figure 1
Number of Smokers and Smoking Prevalence of Population. Both Sexes, 15 Years and Over, 1981-2001

26 April 1988 - The Cabinet approved tobacco control measures, including a ban on advertising, proposed by the
Ministry of Public Health (MOPH). This resolution was forwarded to all ministries to be put into practice.
20 December 1988 - the Thailand Tobacco Monopoly (TTM) complained to the Ministry of Finance, its supervisor,

that after the April cabinet resolution the TTM had ceased its promotional activities, while foreign cigarettes, though
not allowed to be sold legally, continued to advertise in the printed media and on outdoor billboards. The cabinet
therefore ordered the Consumer Protection Board (CPB) to pass a regulation prohibiting tobacco advertising.
10 February 1989 - The Advertising Committee of the CPB made an announcement, published in the Royal Gazette,

that cigarettes are under labelling control, thus cannot be advertised, pursuant to the Consumers Protection Act 1979.

4 August 1992 - The Tobacco Product Control Act (TPCA) 1992 became effective.

World Health Organization

Information about tobacco-related morbidity and mortality
has been fragmented owing to the lack of relevant stud­
ies and surveys. Among cancers of various organs, lung

the packaging of tobacco products for exchange or

redemption therefor;

Section 7: No person shall be allowed to distribute tobacco

cancer was the second most common during 1988-1991.

products as a sample of tobacco products so as to prolif­

The age-standardized incidence rate of lung cancer among

erate such tobacco products or to persuade the public to

women in the Northern region is 37.4 per 100000 - con­

consume such tobacco products except for a customary

sidered to be a high world indicator.

gift;

The advertising ban under the Consumers Protection

Section 8: No person shall be allowed to advertise tobacco

Act 1979, which became effective on 10 February 1989,

products or expose the name or brand of tobacco prod­

was enforced by the office of the CPB which has a wide

ucts in the printed media, via radio broadcast, television

responsibility in the area of consumer protection. Officials

or anywhere else which may be used for advertising pur­

of the CPB were not knowledgeable about tobacco pro­

poses, or to use the name or brand of tobacco products in

motional tactics and did not enforce the law as regards

shows, games, services or any other activity the objective

the ban on tobacco advertising. The secretary of the

of which is to let the public understand that the name or

National Committee of Control of Tobacco Use (NCCTU)

brand belongs to tobacco products.

had to request prosecution in every case of wrongdoing

Therefore the NCCTU secretary, who was the chairman of

The provisions of paragraph one do not apply to live

the tobacco control law drafting committee, incorporated

broadcasts from abroad, via radio or television, and the

the advertising ban in the newly drafted TPCA. Thus the

advertisement of tobacco products in printed media print­

new law would be under the responsibility of the MOPH,

ed outside the Kingdom not specifically for disposal in the

which has more knowledgeable officials. After the TPCA
became effective on 4 August 1992, the announcement of

the CPB Advertising Committee became nullified.

The Tobacco Products Control Act 1992
In this Act, sections relevant to bans on advertising and
promotion are as follows:

Section 3: "Advertising" means an act undertaken by any

means to allow the public to see, hear, or know a state­
ment for commercial interest;

Kingdom;

Section 9: No person shall be allowed to advertise goods
using the name or brand of tobacco products as a brand

of such goods in such a manner as to make such a brand
understood to be that of tobacco products;
Section 10: No person shall be allowed to manufacture,

import for sale or general distribution, or advertise any

goods having such an appearance as to be understood to
be an imitation of such tobacco products as cigarettes or
cigars, under the law on tobacco, or of the packaging of

Section 4: No person shall be allowed to dispose of, sell,

said products;

exchange or give tobacco products to a person when it

is known to the former that the buyer or receiver has not

Section 17: Any person violating Section 4 or Section 5

attained eighteen full years of age;

shall be subject to an imprisonment not exceeding one

month or a fine not exceeding 2000 Baht or both;
Section 5: No person shall be allowed to sell tobacco prod­
ucts through vending machines;

Section 18: Any person violating Section 6, Section 7,

Section 9 or Section 10 shall be subject to a fine not
Section 6: No person shall be allowed to do any of the fol­

exceeding 20000 Baht;

lowing:

— to sell goods or render services with the distribution,
addition or gift of tobacco products, or in exchange for

tobacco products, as the case may be;

s all be subject to a fine not exceeding 200000 Baht;
Section 24: In case the violation of Section 4, Section 5,

— to sell tobacco products with the distribution, addition,

^ection 6, Section 8 paragraph one, Section 9, Section 10

gift of, or in exchange for, other goods or services;

h
13 is by manufacturer or importer, the violator
°ffencesSU^eCt t0
penalty twice that Provided for SUCh

— to give or offer the right to attend games, shows,

services or any other benefit as a consideration to

4

Section 19. Any person violating Section 8 paragraph one

the buyer of tobacco products or a person bringing

Thailand Country Report on Tobacco Advertising and Promotion Bans

The Tobacco Products Control Act 1992 contains a very

Direct advertising, for example:

comprehensive ban on advertising and promotion. It can
be summarized as follows:

— installing large outdoor billboards advertising the ciga­

The ban covers all media (Sections 3 and 8).

rette brands Winston, Kent and Salem; billboards were
also placed in the international airport and its tax-free
shops;

The ban is almost complete, and includes sponsor­

ship. Although there is no such term as "sponsorship"
the definition of "advertising" (Section 3) means that
showing, mentioning, or referring to cigarette logos or
products is illegal. Therefore sponsorship, which must

show cigarette logos or product names is considered

an illegal act (Section 8).
— The only exceptions are live radio or television broad­

casts from abroad, and advertisements in printed
media published outside Thailand (Section 8).

— The ban covers all indirect advertising:
• point-of-sale (POS) advertising is not allowed.
Although the law does not specify POS, it is covered

by the phrase, "or anywhere else which may be

used for advertising purposes", in Section 8;
• product placement (Sections 3 and 8);
• trademark diversification (TMD) (Section 9);
• advertising goods that have an appearance such that

they are understood to be in imitation of tobacco
products or of the packaging of said products

— painting the logo "Mild Seven" on the bodies of ciga­

rette delivery vans;
— launching new cigarette brands, such as Waves of
Japan Tobacco Inc., with giveaways, exchanges, etc.

POS advertising, for example:
— placing numerous empty cartons in front of shops;

— placing large dispensers displaying logos, at sales

points;
— suspending mobiles (imitating cigarette packaging) in

such places.

Product placement, for example:
— wearing a t-shirt exhibiting the "Lucky Strike" logo in
a television drama;

— publishing pictures with cigarette logos in magazines
and calendars, advertising other products in newspa­

pers, yearbooks etc.;

— printing cigarette brand names on clothes and post­
cards.

(Section 10); and

• sponsorship (Sections 3 and 8).
The ban covers several promotional activities:

— prohibition of sale to minors (Section 4);

_

prohibition of sale through vending machines (Section

5); and

TMD, for example:
— advertising a "Marlboro Country Tour" on television;
— setting up a billboard with the logo "Winston - Style
of the USA" across a street;

— advertising in newspapers "Kent Leisure Holidays",
"555 The Statesman Collection" and "Camel Boots”.

— prohibition of exchanges, free premiums, redemption,

giveaways, etc. (Sections 6 and 7).

Steps of Implementation

Sport sponsorship, for example:
— football: telecast of the "555 Football Special";

— snooker: telecast of the "555 Asian Snooker Open"

10 February 1989-3 August 1992:
Prohibition under the Consumers Protection

Act 1979

and the "555 World Series Challenge";
— golf: a small billboard with the logo "Salem" at the

venue of the "Singha Beer Pro-Am Tournament";

Because the CPB was not knowledgeable about tobacco

— cricket: a small billboard at the venue of the "Benson

industry tactics, the secretary of the NCCTU monitored
violations and notified the CPB, which then prosecuted

— motorcycling: a "Lucky Strike-Suzuki" team competed

cases accordingly. Violations included the following:

& Hedges Cricket International”;

in a race.
All of these violations were discovered by the NCCTU

secretary and were sent to the CPB for prosecution. Some

5

World Health Organization

cases were investigated and fines resulted, and in some
cases the final result was not known. The fines were up to
40000 Baht, according to the stipulations of the Consumer

Protection Act. The billboards were ordered to be removed
by the CPB.

- cigarettes advertised in Thai Airways’ duty-free price
list. In the May-June 1994 issue there were full-page
advertisements for Marlboro, Dunhill and 555. There

were several cigarette advertisements in the Thai

Airways in-flight magazine "Swasdee". In the January

1994 issue, on one page there were advertisements
After promulgation of the CPB advertising ban, violations

for Marlboro, Mild Seven, Dunhill and 555; there was

of the law by the transnational tobacco companies (TTCs)

advertising for the ”555 Subaru World Rally Team" in

continued the wrongdoing that had existed previously.

the June and August 1994 issues.

Violations and circumventions that occurred long after the

enactment of the advertising ban were either through the
TTCs pretending to be naive, or because they wanted to

test the effectiveness of law enforcement.

POS. In retail outlets selling foreign cigarettes
there were:
— colour pictures of cowboys, the camel logo, and the

logo "get lucky" installed on cigarette cabinets;
4 August 1992-present: Prohibition under

the Tobacco Products Control Act 1992

— large signs showing prices and price reductions for cer­

tain brands.

The Minister of Public Health appointed officials of the
MOPH, the Ministry of Interior, Municipalities, the Excise

Product placement included:

Department, and the Customs Department, to be respon­

— wearing clothes with cigarette logos on television

sible for the enforcement of this law. Approximately
3000-4000 officials were appointed on 25 August 1992

and on 9 June 1993. There was only one meeting, held
shortly after the TPCA enactment, for the appointed offi­
cials to clarify the law. The supposed law enforcers are

from various government agencies with wide-ranging

shows;

— smoking by principal characters, especially the heroes
and heroines, in television shows;

— displaying tobacco brand names in calendars, e.g. a

Honda car calendar depicting several Marlboro logos;

responsibilities. Their superiors are not interested in tobac­

— advertisements for other products in newspapers, e.g.

co control. Most of the appointed MOPH officials have

an advertisement for Shell Oil included a picture of a

several identity cards for enforcing several laws and never

Formula One car displaying both Shell and Marlboro
logos;

utilize them. This is a major flaw of the Thai bureaucratic
system of law enforcement.
Appointed officials from the Institute of Tobacco

Consumption Control (ITCC) of the Department of

— pictures in magazines and on the sports pages of

newspapers showing cigarette logos on cars, athlete’s
clothes, etc.

Medical Services (DMS) are supposed to form the core of
law enforcement in this area. There has been no official

report of violations recorded by the ITCC. The president

of the Thailand Health Promotion Institute (THPI) is at the

TMD included:
— advertising "Winston House" and "Camel Trophy

Adventure Wear" in newspapers;

same time the drafter of the laws, the establisher of the

Office of Tobacco Consumption Control (later the ITCC),
and the former boss of the ITCC director. He used this

informal relationship to push the ITCC director to take

advertising “Camel Trophy Adventure Wear" and

Marlboro Classics" on posters installed in shopping
outlets and in other media on different occasions.

action in several cases of violation of the law, but very

few results were achieved. The THPI is a nongovernmental
organization and the THPI president is a retired govern­

ment official. Both have no authority in law enforcement.

Sport sponsorship included:

participation by the "555 Subaru" team in the AsiaPacific Rally, 3-6 December 1993;
— publicity for a visit by Mild Seven-sponsored Formula

The THPI has been the only organization that has com­

piled lists of practices violating the law. They included:

— Direct advertising, for example:

One driver Michael Schumacher, dressed in his racing

suit. This was followed by the ”95 Formula-1 Festival"

at a department store on 14-30 October 1994;

Thailand Country Report on Tobacco Advertising and Promotion Bans

— THPI research found that in one year (1998-1999) a

cable television station aired 1343 hours of tobacco-

Success of the Intervention

sponsored sports events, consisting of 99 live legal tel­

During the first period (10 February 1989-3 August

ecasts and 1698 repeats. According to the law only live

1992) when the advertising ban was under the Consumer

telecasts are permitted (see Section 8 of TPCA 1992).

Protection Act 1979, the intervention was reasonably suc­

Therefore the repeats are considered illegal.

cessful. Almost all cases notified to the CPB by the NCCTU

Secretary were investigated and led to fines.
Other promotions, for example:
in December 1992, the tax-free shops at the Bangkok

International Airport ran a promotional programme:

people buying goods worth 1000 Baht would be enti­
tled to a reduction of 100 Baht for other goods, includ­

ing cigarettes.

After 4 August 1992, the MOPH became responsible for
the newly enacted Tobacco Products Control Act 1992
and law enforcement has become very weak. The THPI

has been the main monitoring force and provided numer­

ous notifications to the ITCC. Most of these were not
dealt with efficiently. In a few cases, however, suppression
of the tobacco industry's promotional activities was suc­

cessful owing to the THPI's vigilance and strong media
advocacy.

Success Story 1
Defeat of the Olympic Committee of Thailand's attempt to adopt tobacco sponsorship

In October 1990, the secretary of the Olympic Committee of Thailand (OCT) gave a press interview stating that the
OCT would consider accepting TTC sponsorship of sport, and that the OCT would push for amendment of the law
banning cigarette advertising.
On 21 October, the secretary of NCCTU gave a press interview opposing the proposal. This was followed by streams
of news items, columns, and articles supporting and opposing the planned sponsorship. From October 1990 to March

1991, there were 20 news stories and 24 articles in favour of sponsorship; 18 news stories and 15 articles opposed it;

and there were 9 news stories, 7 articles and 1 cartoon expressing a neutral stance. The pro-sponsorship group includ­

ed the Secretary and Treasurer of the OCT, a former Deputy Public Health Minister, and a large number of sport col­
umnists. The opposition consisted of the Secretary of the NCCTU, the Secretary of the No-Smoking Campaign Project,
the Public Health Minister, the Privy Councillor, and some journalists.

After the continuous 5-month debate, the pro-sponsorship group gave up.

World Health Organization

Success Story 2
Thailand was the only country in which the “Subaru-555" logo could not be displayed in the

Asia-Pacific Rally
1993 was the first year of the Asia-Pacific Rally, which was held in six countries: Australia, Hong Kong (now Hong
Kong Special Administrative Region of China)-Beijing (China), Indonesia, Malaysia, New Zealand and Thailand. After
the race, the THPI and its grass-roots allies gave a press conference stating that exhibiting the "Subaru-555'’ logo was

illegal. The MOPH followed up with a letter of protest to the organizers of the rally. The planned domestic rallies - four

in 1993 - were scrapped.

From 1994 on, the "Subaru 555” logo was changed to "Subaru III" when the rallies were held in Thailand.

Success Story 3
Thailand is the only country on the Asian golf circuit in which Davidoff logos are not

displayed

The Asian Professional Golf Association (Asian PGA) had the watch company, Omega, as its main regional sponsor

until 1999, when Davidoff took over. The Asian PGA's "Davidoff Tour" tournaments were held 20 times in 11 coun­
tries.

In Thailand there were 2 tournaments - The Lexus International on 14-17 October 1999, and The Thailand Open on
1-4 December. Both times, local organizers were told by the THPI president that displaying Davidoff logos was illegal.

The Lexus tournament did not heed the warning and the THPI president initiated an arrest by the ITCC staff. The tour­
nament organizer was prosecuted.
Since then, all Davidoff Asian PGA tours held in Thailand have not dared to exhibit the Davidoff logo. Thailand is the
only country on the tour to have "Davidoff-free” competitions.

Taxation (including
Smuggling
Control

Report on Smuggling Control in Spain

WHO/NMH/TFI/FTC/O3.6

pH - li-

Report on Smuggling

Control in Spain
Luk Joossens
Non-Smokers' Rights Association
and the Smoking and Health Action Foundation

Toronto, Ottawa, Montreal

J World Health Organization

World Health Organization

r
Tobacco Free Initiative Headquarters would like to thank the Regional Offices

for their contribution to this project.

WHO Regional Office for Africa (AFRO)

WHO Regional Office for Europe (EURO)

Cite du Djoue

8, Scherfigsvej

Boite postale 6

DK-2100 Copenhagen

Brazzaville

Denmark

Congo

Telephone: +(45) 39 17 17 17

Telephone: +(1-321) 95 39 100/+242 839100

r
WHO Regional Office for the Americas I Pan

WHO Regional Office for South-East Asia (SEARO)

American Health Organization (AMRO/PAHO)

World Health House, Indraprastha Estate

525, 23rd Street, N.W.
Washington, DC 20037

U.S.A.
Telephone: +1 (202) 974-3000

WHO Regional Office for the Eastern

Mediterranean (EMRO)
WHO Post Office

Abdul Razzak Al Sanhouri Street, (opposite Children's
Library)
NasrCity, Cairo 11371

Egypt
Telephone: +202 670 2535

Mahatma Gandhi Road
New Delhi 110002

India
Telephone: +(91) 11 337 0804 or 11 337 8805

WHO Regional Office for the Western Pacific

(WPRO)
P.O. Box 2932

1000 Manila
Philippines

Telephone: (00632) 528.80.01

Report on Smuggling Control in Spain

Introduction
Tobacco smuggling has become a critical public health
issue because it brings tobacco on to markets cheaply,

A huge smuggling problem,

despite low prices

Joossens and Raw (1998, 2000, 2002) showed that tobac­

making cigarettes more affordable and thus stimulates

co smuggling defies apparent economic logic. Common

consumption. The result is an increase in the burden of ill
health caused by its use. According to the tobacco trade

sense might suggest that cigarettes would be smuggled

report World Tobacco 2002 a major feature of the world

from countries where they are cheap (southern Europe, for

example) to expensive countries (such as northern Europe)

cigarette market is the continued growth in smuggling and

and that this is due simply to price differences between

counterfeit trade, which accounts for a minimum of 8% of

these countries, as the tobacco industry claims. Although

the world cigarette consumption at around 400 thousand

this does happen, it is not the largest type of smuggling,

million pieces.®

and in Europe there is far more smuggling from north to

south rather than the reverse.®
Smuggled tobacco products represent both a threat to

public health and to government treasuries, which are los­
ing thousands of millions of dollars or euro in revenue.

Using 1995-1997 data on nine countries from the
European Confederation of Cigarette Retailers and other

sources, Joossens and Raw classified the 15 European

Smuggled cigarettes became a major concern for govern­

Union (EU) countries and Norway as follows: high-smug­

ments and international organizations such as the World

gling countries, with a contraband market share of 10%

Health Organization, the World Customs Organization,

or more (Spain 15%, Austria 15%, Italy 11.5%, Germany

the World Bank, the International Monetary Fund and the

10%), medium-smuggling countries, with a contraband

International Criminal Police Organization (Interpol). At

market share between 5% and 10% (Netherlands 5-10%,

a conservatively estimated average tax of US$ 1.0025 to

Belgium 7%, Greece 8%, and probably Luxembourg and

USS 1.50 per cigarette pack (this is much higher in most

Portugal, but no studies are available), and low-smuggling

developing countries) cigarette smuggling (20 thousand

countries, with a contraband market share of less than

million packs) accounts for USS 25 to USS 30 thousand

5% (France 2%, the United Kingdom 1.5%, Ireland 4%,

million being lost by governments every year.

Sweden 2%, Norway 2%, and probably Denmark and

The tobacco industry has argued that tobacco smug­

Finland, but no studies are available).® The results can be

gling is caused by market forces—by the price differ­

seen in Table 1. (Note that the situation has changed in a

ences between countries, which create an incentive to

number of the countries since the study was done.)

smuggle cigarettes from "cheaper" countries to "more

expensive" ones. The industry has urged governments to
solve the problem by reducing taxes, which will also, it

says, restore revenue. The facts contradict all these asser­
tions. Smuggling is more prevalent in "cheaper" countries

and, where taxes have been reduced, such as in Canada,
consumption has risen and revenue fallen. There are,

however, countries that have solved the problem by better
control, Spain being the most impressive example to date.

There are two main reasons why the example of Spain in
terms of combating smuggling is impressive:

_ The country had a huge smuggling problem, despite
low prices.
- it effectively reduced smuggling without reducing

prices

3

World Health Organization

the cheapest in the European Union, smuggled cigarettes

Table 1

had an estimated market share of 15% in 1995.®

Prices of cigarettes (in USS, June 1997) and level of

smuggling (1995) into countries of the European Union

According to the EU lawsuit against Philip Morris, RJ

Country

Price

2000 in New York under the United States Racketeering

Spain

1.20

high

Portugal

1.75

medium*

Reynolds and Japan Tobacco, filed on 3 November
Level of smuggling

Influenced and Corrupt Organization Act (RICO), Spain
has been a primary destination for smuggled Winston

cigarettes for so long that the smugglers are sometimes

Greece

2.06

medium

Italy

2.07

high

because of the way RJR mark and label their cigarettes,

Luxembourg

2.12

medium*

the company could identify which smuggled RJR cigarettes

in the marketplace had been originally supplied by RJR

known as "Winstoneiros". According to the EU lawsuit,

Netherlands

2.43

medium

Austria

2.69

high

Belgium

2.95

medium

Germany

3.02

high

France

3.38

low

Finland

4.26

low*

Ireland

4.27

low

EU complaint, RJR took steps to prevent the unauthor­

United Kingdom

4.35

low

ized smuggling. They developed a particular presentation

Denmark

4.55

low*

Sweden

4.97

low

Norway

6.27

low

USA, and which were smuggled into the country by per­
sons without authorization of RJR.

As the demand for Winston in Spain rose through the

1990s increased numbers of "lower quality" Winston from
other sources were being smuggled into Spain, interfering

with the smuggling authorized by RJR. According to the

of Winston cigarettes known to the Spanish consumer as
patanegra. The patanegra presentation could be distin­
guished from the other "lower-quality" Winstons by dis­

Notes: The table shows the price (in US$ at 1 June 1997) of

20 cigarettes from the most popular price category. Sources for

prices are the Commission of the European Communities and
the Norwegian Council on Tobacco and Health.
* Probably details of how this index was constructed are given

in the text

tinctive markings and because they did not have the blue

sticker found on most Winston cigarettes.
It was alleged that RJR produced the patanegra presenta­

tion specifically for their best smuggling customers, to

insure that they could maintain their competitive advan­

tage over other smugglers and so that RJR could increase

their market share (because if you can guarantee good
quality you will sell more and increase market share). The

The correlation between high prices and high levels of

patanegra presentation was developed specifically for the

smuggling claimed by the tobacco industry simply does

Spanish market and sold only in Spain. According to the

not exist. In fact, countries with very expensive cigarettes

EU lawsuit, it was one of the examples that showed how

do not have a large smuggling problem. Table 1 shows

RJR maintained and exercised control of the smuggling

high levels of cigarette smuggling in the south of Europe

operations in Spain.®

rather than the north. Other factors than price levels that

make cigarette smuggling more likely include corruption,

Another source of smuggled cigarettes in Spain and the

public tolerance, informal distribution networks, wide­

EU was Andorra. In a 1992 BAT internal tobacco indus­

spread street-selling, and the presence of organized crime.

try document, the illegal cigarette trade in Andorra was
described in the following way:

Effective reduction of smuggling

without reducing prices

Smuggling is a traditional and highly lucrative trade in

Andorra. The growth has increased rapidly in recent years
Spain is one of the few countries in the world to have
tackled smuggling successfully. It did not do so by reduc4

ing tobacco tax. Despite Spanish cigarettes being among

as Andorran supply has replaced that which used to enter

Spain by sea and has been subjected to increased controls
because of the links with the drugs trade." (5)

Report on Smuggling Control in Spain

Between 1997-1998 there was concerted action at nation­
al and European levels to reduce the supply of contraband

Table 3

cigarettes. Close collaboration among the authorities in

Cigarette sales in Spain

Andorra, Britain, France, Ireland, Spain and the European

(thousand million pieces)

Anti-Fraud Office (OLAF) reduced the supply of smug­
gled cigarettes from Andorra. Actions included sealing the

Andorran border, and having civil guard brigades patrol

1996

72

1997

78

1998

87

valleys and hills to make smuggling more difficult. The

European Anti Fraud Unit led a first mission to Andorra
in March 1998, accompanied by representatives from
the neighbouring countries (France and Spain) and from

cigarette exporting countries (Ireland and the United

Kingdom). The enquiries revealed a lack of appropriate

legislative instruments in Andorra to prevent and combat

fraud. In November 1998 a EU Commission mission visited

1999

86

2000

88

2001

90

Source: Comisionado del Mercado de Tabaco

the Andorran Government and found that attitudes had
changed fundamentally. The laws on customs fraud and

Andorra is important because it illustrates the role of

the control of sensitive goods and the law amending the

the tobacco industry. Andorra was not only supplying

criminal code and making smuggling a crime were pub­

illegal cigarettes to the Spanish market but also to the

lished respectively in the Andorran Official Journal on 4

United Kingdom. Exports from the United Kingdom to

March 1999 and 7 July 1999.(6)

Andorra (which has a population of only 63 000) increased

from 13 million cigarettes in 1993 to 1 520 million in
As a result, contraband cigarettes which had accounted

1997. Since few of these cigarettes were legally re-export­

for an estimated 12% of the Spanish market in early

ed and Andorran smokers do not generally smoke British

1997, held only 5% by mid-19991 and only an estimated

brands, then either each Andorran (including children and

2% in 2001. Sales of legal cigarettes increased from

non-smokers) was smoking 60 British cigarettes a day

78 thousand million in 1997 to 87 thousand million in

in 1997 or these cigarettes were being smuggled out of

1998 (see Table 3), and tax revenue increased by 25%

Andorra. It seems obvious that the companies would know

in the same year (see Table 2). According to the Spanish

what was happening to their cigarettes. In a television

customs authorities, their success was not due to control­

interview on the BBC's Money Programme of 8 November

ling distribution at street level, which is almost impossible,

1998, a spokesperson for the tobacco company (Gallaher)

but to reducing the supply into the country at "container

said: “We will sell cigarettes legally to our distributors in

level" through intelligence, customs activity and coopera­

various countries. If people, if those distributors subse­

tion, and technology *1
2.

quently sell those products on to other people who are

going to illegally bring them back into this country, that is

something outside of our control." (7)

Discussion

Table 2
Excise revenue from cigarette sales in Spain, 1996-2000

(billion Pesetas)

1996

_________________________ ______

_______

1997_________ _______
1998__________ ______

1999

___________ -

7000
____
l_Z------ ----------------

443

The tobacco industry has often claimed that smuggling
is more prominent in high-tax countries and that the
best way to tackle cigarette smuggling is by reducing the

demand and by lowering taxes. In fact, cigarette smuggling
516
646
667

742

Source: Spanish Customs and Excise

1 (Ignacio Garcia, Customs and Excise, Madrid, personal

communication)

2 (Ignacio Garcia, Customs and Excise, Madrid, personal
communication)

World Health Organization

occurs in all parts of the world, even in countries where

References____________________

prices are low. Spain had the lowest cigarette prices in
the EU and still had a huge smuggling problem. Cigarette

1

smokers in search of cheaper cigarettes, but by the illegal

2.

supply of international cigarette brands on the Spanish

Joossens L and Raw M. Cigarette Smuggling in Europe:

Who Really Benefits? Tobacco Control, July 1998. http://

market.
Fortunately, the Spanish experience shows also that coor­

Market Tracking International. World Tobacco file 2002.
London: Market Tracking International, 2001.

smuggling in Spain was not caused by the demand of

tc bmjjournals. com/cgi/content/full/7/1/66

3.

dinated action to stop the illegal cigarette supply can

Joossens Raw L & M. How can cigarette smuggling be

reduced? British Medical Journal 321:947-950, 14 October

solve the smuggling problem. The proportion of smuggled

2000. http://bmi.com/cgi/content/full/321/7266/947

cigarettes in the Spanish market was reduced dramati­
cally and revenue was increased, without lowering taxes,

4.

EU complaint against Philip Morris, RJR and Japan

whereas tax reductions produced disastrous results - lower

Tobacco International, November 2000. http:

revenues and a sharp increase in consumption, especially

//www.nyed.uscourts.gov/pub/rulings/cv/2000/

among young people - in Canada. (3) Governments need
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ply-driven process and that manufacturers exercise a

00cv6617cmp.pdf

5.

and illegal, as testified to by many documents from the

BAT document, Andorra contract manufacture proposal,
secret, 22 May 1992, bates number 503095358-64.

large degree of control over their end markets, both legal
6.

Commission of the European Communities, Protecting the

Guildford archives.® What follow logically from this, is the

Communities' financial interests and the fight against fraud

need to cut off the supply of cigarettes to the smugglers.

- Annual report 1998, COM (1999) 590 final, Brussels, 17

December 1999.

Economic analysis of the effect of cigarette prices in Spain

and the analysis of smoking histories from the national

7.

BBC. Money Programme. London, BBC, 8 November 1998.

health survey 1993-1995-1997 has shown that the price

increase of black cigarettes had a significant effect on

8.

Joossens L, Raw M. Turning off the tap, An update on ciga­

prevalence, but the price increase of blond cigarettes did

rette smuggling in the UK and Sweden with recommenda­

not.® Smuggling may be an explanation for this dif­

tions to control smuggling, Brussels, London, June 2002.

ference between the effect of price increases of blond

9.

Nicholas AL. How important are tobacco prices in the

and dark cigarettes as smuggling of cigarettes in Spain

propensity to start and quit smoking? An analysis of smok­

occurred mainly with blond (Winston) cigarettes, which

ing histories from Spanish National Health Survey, Health

were promoted on the illegal market as "high-quality

Economics, 11:521-535 (2002).

cigarettes" (the so called Patanegra Winstons). The ready
availability of lower-price smuggled blond cigarettes

undermined the effect that price increases of legitimately
sold cigarettes should have had.

While the success of the fight against smuggling in Spain

was evident, the impact of the reduction of smuggling on

smoking prevalence is unclear. Smoking prevalence among
women remained stable at 27% in 1995 and 2000-2001,

but decreased among men from 47% in 1995 to 42% in
2000-2001. (70) It is unclear whether the decline of smok­

ing among men is linked to the reduction of cigarette
smuggling, but it might be, since the action against smug­

gling greatly reduced the ready supply of cheap Winstons
available to consumers.

10.

Ministerio de Sanidad y Consume, Encuesta Nacional de

Salud 2001, Avance de resultados, Madrid, 2002.

pH-) 2^

SACIob
Recommendation
on Nicotine and the Regulation in
Tobacco and non-Tobacco Products

World Health Organization
Tobacco Free Initiative

WHO Library Cataloguing-in-Publication Data
WHO Scientific Advisory Committee on Tobacco Product Regulation.
SACTob recommendation on nicotine and the regulation in tobacco
and non-tobacco products I Scientific Committee on Tobacco
Regulation (SACTob).

l.Nicotine - pharmacology 2.Nicotine - standards 3.Tobacco chemistry 4.Smoking I.Title
ISBN 92 4 159092 0

(LC/NLM classification: HD 9130.6)

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Printed in World Health Organization, Geneva.

Preface
The Scientific Advisory Committee on Tobacco Product Regulation (SACTob),
established by the World Health Organization, held its first meeting in October 2000.
The committee is composed of national and international scientific experts on product
regulation, smoking cessation and laboratory analysis. SACTob advises WHO about
scientifically sound recommendations to Member States addressing the most effective
and evidence-based means to achieve a co-ordinated regulatory framework for tobacco
products. The work of the committee is based on recent leading edge research on
tobacco product issues and aims to fill the regulatory gaps in tobacco control.
The present recommendation was finalized by SACTob during its Fourth Meeting in
4-6 February 2002 held at Oslo, Norway.

SACTob Position Statement on Nicotine and Its Regulation
in Tobacco and Non-Tobacco Products.
Background
Over the past two decades a wealth of research findings have pointed to nicotine as the
key pharmacological factor underlying tobacco use. The 1988 report of the US Surgeon
General identified cigarette smoking as nicotine addiction (1); the Royal College of
Physicians similarly concluded that nicotine is an addictive drug on par with heroin and
cocaine, and that the primary purpose of smoking tobacco is to deliver a dose of
nicotine rapidly to the brain (2). The Diagnostic and Statistical Manual of Mental
Disorders [D.S.M-IV] classifies nicotine-related disorders into the sub-categories of
dependence [305.10] and withdrawal [292.0] which may develop with the use of all
forms of tobacco (3). The effects of tobacco and nicotine to produce dependence and
withdrawal are also identified by the International Statistical Classification of Diseases
and Related Health Problems [I.C.D-10] as a disease in the category [T 65.2] ‘Toxic
effect of other and unspecified substances’ (4).

While nicotine is acknowledged to be the primary reinforcer of smoking (5,6), and
nicotine-free cigarettes have consistently failed in the marketplace (7), exposure to
nicotine in itself is believed not to be responsible for more than a minor portion of
tobacco related disease (8). Rather, harmful gases and particulates, which can be
thought of as contaminants of the cigarette as a nicotine delivery device (9), cause the
great majority of smoking related diseases and their specific role in the reinforcing
effects of smoking is not well understood.

Despite their toxicity, tobacco products have enjoyed an unprecedented degree of
freedom from the regulations that apply to food and drug products and to consumer
products generally (10,11). Paradoxically, pure nicotine products designed to aid
smokers trying to quit (12), are subject to stringent regulation and are required to meet
the same standards of safety and product information as any other pharmaceutical
preparation (13,14,15,16).

It is theoretically possible that changes in cigarette design could lower exposure of
smokers to the harmful constituents in smoke, but efforts to do so through so called
“low vield" cigarettes have failed (2. 17). Smokers self-dose for nicotine, and they
smoke more intensively or smoke more cigarettes per day to obtain the dose that will
Xe them satisfaction (9, 15, 16, 17. 18). Most so called “low-yield cigarettes are
°
, eiirh ,hal theSe changes in smoking behaviour return the delivery of nicotine

S'i X—«r



“high-yield ” Cigarettes (19). Dependence on nicotine is a btolog.cal force that doves
such behaviour (1,2,20).

Proposals for more effective nicotine regulation have ranged from reducing nicotine
availability from cigarettes to the point where they are no longer reinforcing (6,21) to
restricting unwanted particulate and gas phase components while accepting a laissez
faire approach to nicotine (7, 22, 23, 24). A common thread is the recognition of the
need to level the regulatory playing field, as between consumer and pharmaceutical
nicotine products (14, 25, 26), as well as the need to ensure that the future market for
nicotine does not continue to be dominated by the most contaminated product, the
cigarette (27).

Based on the existing science, SACTob makes the following recommendations:

1.

The present situation in which the most toxic form of nicotine delivery is the least
regulated, is unacceptable from a public health perspective.

2.

Because nicotine appears to be responsible for a small proportion of tobacco-caused
diseases relative to other tobacco constituents and emissions, there is considerable
scope for developments that reduce the risks experienced by users of tobacco, but
without undermining efforts to prevent initiation to tobacco use and promote
cessation among established users.

3.

In the absence of firm contrary data, those responsible for public policy decisions
are justified in using the conservative assumptions that smokers’ preferences for a
nicotine dose are persistent over time and are not influenced by changes in the
product used and that smokers will compensate for reductions in yield to maintain a
relatively consistent dose of nicotine.

4.

A broad and comprehensive regulatory framework is required to enable policy
options for controlling nicotine to move forward in ways that minimise the risks.

References:
(1)
US Department of Health and Human Services. The health consequences of smoking:
nicotine addiction. A Report of the Surgeon General. Washington DC: US Government
Printing Office; 1988.

(2)
Royal College of Physicians. Nicotine Addiction in Britain. London: Royal College of
Physicians; 2000.
(3)
American Psychiatric Association. Substance-Related Disorders. Diagnostic and
Statistical Manual of Mental Disorders. Washington D.C; Fourth edition 1994: 242-247.
(4)
World Health Organization. Injury. Poisoning and certain other consequences of
External Causes. International Statistical Classification of Diseases and Related Health
Problems 1992 ;Volume-I. Chapter XIX: 985.

(5)
Balfour DJ. The neurobiology of tobacco dependence: a commentary. Respiration 2002’
69(1): 7-11.
(6)
Henningfield J.E, Benowitz N.L, Slade J. Houston T.P, Davis R.M, Deitchman S.
Reducing the addictiveness of cigarettes. Tobacco Control 1998;7: 281-293.
(7)
Bates C. Taking the nicotine out of cigarettes- why it is a bad idea. Bulletin of the
World Health Organization 2000; 78(7) : 944.

(8)
Benowitz, N. L., Ed. (1998). Nicotine safety and toxicity. New York. Oxford University
Press.
(9)
Stratton, K., P. Shetty, Wallace R, Bondurant S. (Eds). Clearing the Smoke: Assessing
the Science Base for Tobacco Harm Reduction. Washington, D.C., National Academy
Press. 2000.

(10)
Slade J, Henningfield J. Tobacco product regulation: context and issues. Food and
Drug Law Journal 1998; 53:43-74.
(11)
Bates C. McNeill A, Jarvis M. Gray N. The future of tobacco product regulation and
labelling in Europe: implications for the forthcoming European Union Directive.Tobacco
Control 1999; 8: 225 - 235.

(12)
Kunze U. Schoberberger R. Schmeiser- Rieder A, Groman E. Kunze M. Alternative
nicotine delivery systems (ANDS) - public health aspects. Wiener Klinische Wochenschrift
1998 Dec 11; HO (23): 811-6.
(13)
Page J. Federal regulation of tobacco products and products that treat tobacco
dependence: are the playing fields level? Food and Drug Law Journal 1998; 53:11-42.
(14)
McNeill A, Foulds J. Bates C. Regulation of nicotine replacement therapies (NRT): a
critique of current practice. Addiction 2001; 96: 1757-1768.
(15)
West R. Addressing regulatory barriers to licensing nicotine products for smoking
reduction. Addiction 2000 Jan: 95 Supple 1: S29-34.

3

(16)
Henningfield J.E. Slade J. Tobacco dependence medications : Public health and
regulatory issues. Food and Drug Law Journal. 1998 53, Supple.: 75-114.
(17)
National Institutes of Health (2001). Risks associated with smoking cigarettes with low
machine-measured yields of tar and nicotine. Bethesda. MD, Department of Health and
Human Services. National Institutes of Health. National Cancer Institute.
(18)
Hoffman D. Hoffman I, El-Bayoumy K. The less harmful cigarette: a controversial
issue. A tribute to Ernst L. Wynder. Chemical research in toxicology.2001; 14(7) : 767-990.
(19)
Jarvis M. Primatesta P. Boreham R. Feyerabend C. Nicotine yield from machine
smoked cigarettes and nicotine intakes in smokers : evidence from a representative
population survey. Journal of the National Cancer Institute 2001 ; 93:134-138.
(20)
Djordjevic MV. Hoffman D, Hoffman I. Nicotine regulates smoking patterns.
Preventive Medicine.1997 ; 26(4) : 435-40.

(21)
Benowitz NL, Henningfield JE. Establishing a nicotine threshold for addiction - The
implications for tobacco regulation. New England Journal of Medicine 1994: 331(2): 123125.
(22)
Russell MA. Realistic goals for smoking and health. A case for safer smoking. Lancet
.1974:16: l(851):254-8.

(23)
Russell MAH. The future of nicotine replacement. British Journal of Addiction 1991:
86(5):653-658.
(24)
238.

Bates C. What is the future for the tobacco industry? Tobacco Control 2000;9: 237-

(25)
Warner K E, Slade J. Sweanor DT. The emerging market for long-term nicotine
maintenance. JAMA 1997; 278: 1087-1092.
(26)
Warner K.E, Peck C.C., Woosley R.L, Henningfield J.E, Slade J. Treatment of tobacco
dependence innovative regulatory approaches to reduce death and disease, Preface. Food
and Drug Law Journal July 1998 53 Supple. 1-9.
(27)
Hurt RD. Robertson CR. Prying open the door to the tobacco industry’s secrets about
nicotine: the Minnesota Tobacco Trial. JAMA 1998: 280(13): 1173-81.

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Tobacco Free Initiative
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