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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.
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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.
WHO Regional Office for Africa (AFRO)
WHO Regional Office for Europe (EURO)
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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.
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tobacco products. Has it worked? Oslo: Norwegian Cancer
Society/Norwegian Health Association, 1998 Available on
web site: www.kreft.no.
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Bjartveit K. Legislation and political activity. In: Forbes WF,
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Health: 31-45, 1983.
3.
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Kjonstad A. The tobacco industry and the ban on advertising.
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We can and should put an end to all sales promo
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The Act relating to Restrictive Measures for the Marketing of
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Bjartveit K. Fifteen years of comprehensive legislation: results
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and Health 1990. The Global War. Proceedings of Seventh
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Norwegian; quotes in English).
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14
Lund KE. Tobacco advertising and how to measure its effect
Acknowledgements
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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
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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.
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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.
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Cite du Djoue
Botte postale 6
WHO Regional Office for Europe (EURO)
8, Scherfigsvej
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Telephone: +(91) 11 337 0804 or 11 337 8805
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Telephone: (00632) 528.80.01
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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
and health warning messages on cigarette smokers - survey
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of adults and adult smokers - Wave 2 surveys (Research pre
The author would like to thank Francis Thompson and Francois
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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
All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination,
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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.
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
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Tobacco Free Initiative Headquarters would like to thank the Regional Offices
for their contribution to this project.
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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
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4.
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5.
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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.
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Markham V, Toong R. Reactions and Attitudes to Health
(Smoking in Enclosed Places) Regulations 1999, 2001,
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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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The named authors alone are responsible for the views expressed in this publication.
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.
WHO Regional Office for Africa (AFRO)
WHO Regional Office for Europe (EURO)
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American Health Organization (AMRO/PAHO)
2
WHO Regional Office for South-East Asia (SEARO)
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Telephone: (00632) 528.80.01
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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
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Supplement 5 Part 1 pp 1-17.
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onwards. London, Department of Health, July 2000.
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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
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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.
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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
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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
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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
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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
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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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Raw M, McNeill A, West R. Smoking cessation guidelines for
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Stapleton J. Cost effectiveness of NHS smoking cessation
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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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The named authors alone are responsible for the views expressed in this publication.
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
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 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
References
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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://bmj.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
Tobacco International, November 2000. http:
whereas tax reductions produced disastrous results - lower
revenues and a sharp increase in consumption, especially
//www.nyed.uscourts.gov/pub/rulings/cv/2000/
among young people - in Canada. (3) Governments need
00cv6617cmp.pdf
to acknowledge that smuggling is, to large extent, a sup
5.
ply-driven process and that manufacturers exercise a
BAT document, Andorra contract manufacture proposal,
secret, 22 May 1992, bates number 503095358-64.
large degree of control over their end markets, both legal
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
7.
8.
Joossens L, Raw M. Turning off the tap, An update on ciga
rette smuggling in the UK and Sweden with recommenda
prevalence, but the price increase of blond cigarettes did
tions to control smuggling, Brussels, London, June 2002.
not.® Smuggling may be an explanation for this dif
ference between the effect of price increases of blond
BBC. Money Programme. London, BBC, 8 November 1998.
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. (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
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
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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)
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 the Americas / Pan
American Health Organization (AMRO/PAHO)
525, 23rd Street, N.W.
Washington, DC 20037
WHO Regional Office for South-East Asia (SEARO)
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New Delhi 110002
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
Abdul Razzak Al Sanhouri Street, (opposite Children’s
P.O. Box 2932
1000 Manila
Library)
Philippines
Nasr City, Cairo 11371
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
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0
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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.
© World Health Organization 2003
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New Zealand:
Effective Access to Tobacco
Dependence Treatment
Liz Price and
Matthew Allen
Allen & Clarke Policy and Regulatory Specialists
Limited
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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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
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,
city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
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.
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)
WHO Regional Office for Europe (EURO)
Cite du Djoue
8, Scherfigsvej
Bolte postale 6
DK-2100 Copenhagen
Brazzaville
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Telephone: +(45) 39 17 17 17
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WHO Regional Office for the Americas / Pan
American Health Organization (AMRO/PAHO)
WHO Regional Office for South-East Asia (SEARO)
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Philippines
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Telephone: (00632) 528.80.01
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Telephone: +202 670 2535
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,
city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
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.
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.
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)
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 Eastern
WHO Regional Office for the Western Pacific
(WPRO)
Mediterranean (EMRO)
P.O. Box 2932
WHO Post Office
Philippines
Library)
Telephone: (00632) 528.80.01
Nasr City, Cairo 11371
Egypt
Telephone: +202 670 2535
2
1000 Manila
Abdul Razzak Al Sanhouri Street, (opposite Children's
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.
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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.
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Musk AW et al. Progress on smoking control in Western
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Tobacco in Australia: Facts and Issues. Victorian Smoking and
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Holman CD, Donovan RJ, Corti B. Report of the evaluation
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Western Australian Drug Strategy. Protecting the commu
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Corti B et al. Warning attending a sport, racing or arts venue
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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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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.
References
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
results. Presented at No Tobacco Day commemorations 2002,
Brazil.
British American Tobacco (1992) Public Affairs, Topics in Smoking
and Health Bible, Bates no. 500887603/604.
Ministerio da Saude (1998) Falando sobre Tabagismo. Secretaria
Nacional de Assistencia a Saude. Instituto Nacional de Cancer.
British American Tobacco Competitor Activity Report (1994) Bates
Coordenacao Nacional de Controle do Tabagismo e Prevenjao
no. 301724407/408.
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
ismo no Brasil - 30 anos de a?ao. Jovem MEdico, Vol. 6:. 54-59.
of Health and Human Services, Public Health Service, Agency for
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.
In: Clinical Practice Guideline. U.S. Department of Health and
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
Principles and Management Orleans CT and Slade J, New York,
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.
2000.
World Bank (1999) Curbing the Epidemic. Governments and the
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
1.
2.
Experts tackle religious, health issues on smoking. The Jordan
2.
World Health Organization, Amman office, personal inter
3.
Morbidity Study, Johns Hopkins University, Ministry of
4.
Department of Statistics, 1996.
5.
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
5.
Jordanian National Cancer Registry, personal interview with Dr
Bassem Hijawi
view with Dr Ala'a Alawa.
4.
Jordan Health Ministry, Education Department, personal inter
view with Muna Hamzeh.
Times, 26 May 2002.
3.
Jordan Health Ministry, Tobacco Control Programme, personal
interview with Dr Hiba Ayoub.
vey
6.
The United Nations Children's Fund, personal interview with
Lara Hussein.
Advertising and
Promotion
Bans
A Report on
Smoking Advertising
and Promotion Bans in the
Islamic Republic of Iran
WHO/NMH/TFI/FTC/03.15
A Report on Smoking Advertising
and Promotion Bans in
The Islamic Republic of Iran
Ministry of Health and Medical
Education Deputy of Health
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
References
tive sample of 7 387 adults, the other among 299 young
sters. Nine per cent of the adult smokers, who had seen
1
Joossens L. Success and failure in tobacco control in the
the new warnings said they smoked less and 16% were
European Union. Presentation at the Fifth WHO seminar for
more motivated to quit. The effect of the warnings was
a Tobacco-Free Europe. Warsaw, 26-28 October 1995.
even stronger on adolescents (13-18-year-olds) Twenty
2
eight per cent of youngsters said they smoked less because
Richonnier M. The EC decision-making process: an inside
view. The case of the Anti-Tobacco Fight The Center for
of the new health warnings. Moreover, the results showed
International Affairs, Cambridge, MA, Harvard University,
that very few youngsters thought the new warnings were
1990.
''cool". Only 5% of the youngsters, who knew about the
new health warnings, tried to collect all 14 warnings <7).
3
Health Education Authority. Health warnings on cigarette and
tobacco packs: report on research to inform European stand
ardisation, London, 1990.
« Action on Smoking and Health. Tobacco product warnings: a
survey of effectiveness, London, 1998.
5
Naett C, Howie C. The labelling of tobacco products in the
European Union. Report undertaken by the European Bureau
for Action on Smoking Prevention at the request of the
European Commission, Brussels, 1993.
6
Advancing knowledge on regulating tobacco products.
International Conference on regulating tobacco products,
WHO Tobacco Free Initiative in collaboration with the
Norwegian Ministry of Health, Oslo, 9-11 February, 2000,
World Health Organization, 2001.
7
Persbericht Defacto: 28% van jonge rakers rookt minder door
de nieuwe waarschuwingen op verpakking, Den Haag 26
november 2002.
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
Telephone: (00632) 528.80.01
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
Preference of Adolescent Smokers - United States, 1989-
believes the policies are important. Tobacco advertis
1993. Morbidity Mortality Weekly Report, 43: 577- 81
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,
Government Printer, Gaborone.
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
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11
Labelling and Packaging
(including Health
Warrant’2}
Thailand Country Report
on Labelling and Packaging
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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
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Telephone: +(45) 39 17 17 17
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WHO Regional Office for the Americas / Pan
American Health Organization (AMRO/PAHO)
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Telephone: +1 (202) 974-3000
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WHO Regional Office for the Eastern
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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
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Telephone: +(45) 39 17 17 17
Telephone: +(1-321) 95 39 100/+242 839100
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WHO Regional Office for the Americas I Pan
WHO Regional Office for South-East Asia (SEARO)
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Telephone: +1 (202) 974-3000
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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
to acknowledge that smuggling is, to large extent, a sup
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)
© World Health Organization 2003
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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.
w
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Tobacco Free Initiative
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