Moving East: how the transnational tobacco industry gained entry to the emerging markets of the former Soviet Union-part I: establishing cigarette imports

Advocacy counterstrategies to tobacco industry interference in policymaking: a scoping review of peer-reviewed literature

BACKGROUND

There has been remarkable tobacco control progress in many places around the globe. Tobacco industry interference (TII) has been identified as the most significant barrier to further implementation of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). Civil society has been recognised as a key actor in countering TII. While TII has been extensively studied for several decades now, there is little research that focuses on counteractions to limit it and their effectiveness to do so. This scoping review seeks to map the peer-reviewed literature on civil society's activities of countering TII in policymaking to identify common counterstrategies and assess their effectiveness.

METHODS

Data sources: We searched Embase, IBSS, JSTOR, PubMed, Science Direct, Scopus and Web of Science using the following terms: ("Tobacco industry" OR "Tobacco compan*") AND. ("corporate political activity" OR "CPA" OR "lobbying" OR "interference") AND ("advoca*" OR "counter*" OR "activi*"), without time or language restrictions.

STUDY SELECTION

Our selection criteria included peer-reviewed studies that were written in English, German, or Spanish that drew on primary data and/or legal and policy documents and reported at least one specific example of civil society members or organisations countering tobacco industry action-based strategies.

DATA EXTRACTION

Advocates' counterstrategies were analysed inductively and countered industry strategies were analysed using the Policy Dystopia Model (PDM). Perceptions of effectiveness of countering attempts were analysed descriptively.

RESULTS

We found five common counterstrategies among 30 included papers covering five WHO regions; 1. Exposing industry conduct and false claims; 2. Accessing decision-makers; 3. Generating and using evidence; 4. Filing a complaint or taking legal action; 5. Mobilising coalition and potential supporters. These counterstrategies were used to work against a wide range of industry strategies, which are captured by five action-based strategies described in the PDM (Coalition Management, Information Management, Direct Access and Influence, Litigation, Reputation Management). While some studies reported the outcome of the countering activities, their impact remained largely underexplored.

CONCLUSION

The review shows that peer-reviewed literature documenting how civil society actors counter TII is scarce. It suggests that advocates employ a range of strategies to counter TII in its different forms and use them flexibly. More work is needed to better understand the effects of their actions. This could stimulate discussions about, and facilitate learning from, past experiences and help to further enhance advocates' capacity.

Trends and risk factors of global incidence, mortality, and disability of genitourinary cancers from 1990 to 2019: Systematic analysis for the Global Burden of Disease Study 2019

Background

The incidence of kidney, bladder, and prostate cancer ranked ninth, sixth, and third in male cancers respectively, meanwhile, the incidence of testicular cancer also increased gradually in the past 30 years.

Objective

To study and present estimates of the incidence, mortality, and disability of kidney, bladder, prostate, and testicular cancer by location and age from 1990 to 2019 and reveal the mortality risk factors of them.

Materials

The Global Burden of Diseases Study 2019 was used to obtain data for this research. The prediction of cancer mortality and incidence was based on mortality-to-incidence ratios (MIRs). The MIR data was processed by logistic regression and adjusted by Gaussian process regression. The association between the socio-demographic index and the incidence or disease burden was determined by Spearman's rank order correlation.

Results

Globally in 2019, there were 371,700 kidney cancer cases with an age-standardized incidence rate (ASIR) of 4.6 per 100,000, 524,300 bladder cancer cases, with an ASIR of 6.5 per 100,000, 1,410,500 prostate cancer cases with an ASIR of 4.6 per 100,000 and 109,300 testicular cancer incident cases with an ASIR of 1.4 per 100,000, the ASIR of these four cancers increased by 29.1, 4, 22, and 45.5% respectively. The incidence rate of the four cancers and the burden of kidney cancer were positively correlated with the socio-demographic index (SDI), regions with a higher SDI faced more of a burden attributable to these four cancers. High body-mass index has surpassed smoking to be the leading risk factor in the past thirty years for kidney cancer mortality. Smoking remained the leading risk factor for cancer-related mortality for bladder cancer and prostate cancer and the only risk factor for prostate cancer. However, the contribution of high fasting plasma glucose to bladder cancer mortality has been increasing.

Conclusion

The incidence of bladder, kidney, prostate, and testicular cancer is ever-increasing. High-income regions face a greater burden attributable to the four cancers. In addition to smoking, metabolic risk factors may need more attention.

Understanding the long-term policy influence strategies of the tobacco industry: two contemporary case studies

OBJECTIVE

This paper explores transnational tobacco companies' (TTCs) long-term policy influence strategies using two case studies, harm reduction and illicit tobacco, to identify lessons for the tobacco control movement and wider efforts to address the commercial determinants of health.

METHODS

Evidence from a broad combination of sources including leaked documents and findings from over two decades of TTC monitoring were reviewed for each case study and categorised using the Policy Dystopia Model, focusing on the primary discursive strategy and key instrumental (action-based) strategies used.

RESULTS

In both case studies, TTCs seek to advance their interests by engaging primarily in reputation management, coalition management and information management strategies over the long-term to propagate their over-riding discursive strategy-'we've changed, we are part of the solution'-despite clear evidence from both case studies that this is not the case. These strategies are globally coordinated and attempt primarily to reshape norms towards TTC involvement in tobacco control policy and delivery. Findings also suggest that industry denormalisation and the advent of Article 5.3 have led to the TTCs growing use of increasingly complex and opaque 'webs of influence'.

CONCLUSIONS

The tobacco control community must develop its own proactive long-term strategies which should include industry denormalisation, new ways to fund research that reduce industry control, and improved transparency measures for research and policy. These findings, including TTC adaptations to Article 5.3, also indicate the need for more structural solutions, addressing corporate power and the underlying political and economic system. These lessons can be applied to other unhealthy commodity industries.

Turning a threat into an opportunity: British American Tobacco's weakening of the Protocol to Eliminate Illicit Trade in Tobacco Products

BACKGROUND

Previous research has outlined transnational tobacco company (TTC) efforts to undermine implementation of the Protocol to Eliminate Illicit Trade in Tobacco Products (Protocol) and evidence of ongoing TTC complicity in the illicit tobacco trade (ITT). However, the industry's views on the Protocol and role in its development are not well understood.

METHODS

Systematic searching and analysis of leaked documents-approximately 15 000 from British American Tobacco (BAT) and 35 from Philip Morris International, triangulated via searches of online resources and interviews with five stakeholders across academia, international organisations, governments, civil society and the private sector.

FINDINGS

Evidence indicates that after privately viewing the Protocol as a significant threat (2003), BAT worked to influence its content, while publicly signalling support for it (2007-2012), and was largely satisfied with the final text. BAT successfully pushed for a non-prescriptive text which enabled further country-level TTC influence during the Protocol's implementation phase. The final text also reflected other BAT policy preferences, including preventing outright bans on duty-free sales and intermingling, and making it difficult to sanction and hold tobacco companies accountable for ongoing involvement in the ITT. TTC representatives were present during early Protocol negotiations, despite rules against this, and BAT obtained draft texts before they were public and paid at least one delegate to support its position.

CONCLUSIONS

BAT's primary interest in shaping the Protocol was to minimise its financial and legal costs for BAT while maximising potential costs to small competitors. These findings raise concern about the Protocol's ability to control the ITT, particularly given TTCs' intention to influence ongoing national implementation. An effective Protocol is vital to controlling both the ITT and ongoing tobacco industry involvement in it and, in turn, governments' ability to increase tobacco taxes and thereby save lives.

Developing more detailed taxonomies of tobacco industry political activity in low-income and middle-income countries: qualitative evidence from eight countries

INTRODUCTION

Historical evidence, predominantly from high-income countries (HICs), shows that the tobacco industry uses a recurring set of arguments and techniques when opposing tobacco control policies. This data formed the basis of a model of tobacco industry political activity known as the policy dystopia model (PDM). The PDM has been widely used in tobacco control research and advocacy and has subsequently been shown relevant to other unhealthy commodities industries in both HICs and low-income and middle-income countries (LMICs). Before it can be validated as a generic tool for researching corporate influence on policy, one needs to determine whether the PDM successfully captures contemporary corporate political activities in LMICs.

METHOD

We conducted semistructured interviews with 22 LMIC-based advocates and used the transcripts as the primary data source. The discursive and instrumental taxonomies constituting the PDM served as the starting point for the coding framework. Using thematic analysis, we combined deductive and inductive coding to ensure we captured all strategies from the PDM and the interviews.

RESULTS

This study found that the tobacco industry uses a set of discursive and instrumental strategies that is largely consistent across LMICs and with the PDM. We identified several minor contextual nuances absent from the PDM. Some of these nuances were characteristic to individual countries, while others to LMICs more broadly. They included the argument that tobacco control policies unfairly punish reputable tobacco industry actors, and an emphasis on instrumental strategies centred around maintaining a good image, rather than rehabilitating a tarnished image as emphasised in the PDM.

CONCLUSIONS

Allowing for the nuances identified in this study, the PDM has been found to be fit for purpose. The revised model should now be tested through in-depth LMIC case studies and could be used to facilitate comparative studies of unhealthy commodity industries' political activities.

Multimorbidity from Chronic Conditions among Adults in Urban Slums: The AWI-Gen Nairobi Site Study Findings

Background:

In the era of double burden of infectious and non-communicable diseases in sub-Saharan Africa, the burden of multimorbidity is likely to be common. However, there is limited evidence on the burden and its associated factors in the sub-Saharan African context.

Objective:

The aim of this study was to determine the levels and identify determinants of multimorbidity from chronic conditions in two urban slums in Nairobi.

Methods:

Data collected from 2003 study participants aged 40–60 years in two urban slums of the Nairobi Urban Health and Demographic Surveillance System in 2015 were used. Using self-report, anthropometry and key biomarkers, data on 16 conditions including chronic diseases, behavioral disorders and metabolic abnormalities were gathered. Lifetime multimorbidity defined by the occurrence of at least two chronic conditions in an individual at any time during their life course was computed. Factors associated with lifetime multimorbidity were identified using multiple logistic regression.

Findings:

A total of 2,081 chronic conditions were identified among 1,302 individuals. While 701 (35.0%) had no chronic condition, single morbidity was reported in 726 (36.2%) of the study population. The overall prevalence of lifetime multimorbidity was 28.7%. The prevalence of dyads and triads of simultaneous occurrences of conditions (episodic multimorbidity) was 20.8% and 6.1%, respectively. Single morbidity was positively associated with gender and alcohol consumption; and negatively associated with employment. Women, older people, the unemployed, current smokers and current alcohol consumers had higher levels of lifetime multimorbidity in the study population.

Interpretation:

The findings of this study indicate that a considerable proportion of adults living in urban slums experience multimorbidity from chronic conditions. Further studies with a better rigor to establish temporal associations between socio-demographic factors and the occurrence of chronic conditions are needed to explore the impacts and implications on health status and health system.

Tracking and tracing the tobacco industry: potential tobacco industry influence over the EU's system for tobacco traceability and security features

BACKGROUND

Subsequent to the transnational tobacco companies' (TTC) history of involvement in tobacco smuggling, the Illicit Trade Protocol (ITP) requires that tobacco tracking and tracing (T&T) systems be established independent of the industry. In response, TTCs developed a T&T system, originally called Codentify, promoting it via an elaborate set of front groups to create a false impression of independence. The European Union (EU) is one of the first and largest jurisdictions to operationalise T&T. We explore how industry efforts to influence T&T have evolved.

METHODS

Analysis of tobacco industry documents, policy documents, submissions to a relevant consultation and relationships between the tobacco industry and organisations proposed by it and approved by the European Commission to provide a data repository function within the EU's T&T system.

FINDINGS

17 months after TTCs sold Codentify to Inexto and Philip Morris International claimed Inexto was independent, leaked documents suggest TTCs and Inexto continued to have a financial and operational relationship. Inexto's meetings with TTCs, engagement with EU Member States and promotion of industry-favoured technical standards suggest TTCs influenced Inexto's activities, using the company to undermine EU T&T. The EU's T&T system appears to be inconsistent with the ITP due to its 'mixed' governance and seven of eight organisations approved as data repository providers having pre-existing industry business links.

CONCLUSIONS

TTC's efforts to maximise their control and minimise external scrutiny of T&T systems seriously limit attempts to address tobacco smuggling. Countries implementing T&T should be alert to such efforts and should not replicate the EU system.

Impact of tobacco tax increases and industry pricing on smoking behaviours and inequalities: a mixed-methods study

Background

Increasing tobacco prices through taxation is very effective for reducing smoking prevalence and inequalities. For optimum effect, understanding how the tobacco industry and smokers respond is essential. Tobacco taxation changes occurred in the UK over the study period, including annual increases, a shift in structure from ad valorem to specific taxation and relatively higher increases on roll-your-own tobacco than on factory-made cigarettes.

Objectives

Understanding tobacco industry pricing strategies in response to tax changes and the impact of tax on smokers’ behaviour, including tax evasion and avoidance, as well as the effect on smoking inequalities. Synthesising findings to inform how taxation can be improved as a public health intervention.

Design

Qualitative analysis and evidence synthesis (commercial and Nielsen data) and longitudinal and aggregate cross-sectional analyses (International Tobacco Control Policy Evaluation Project data).

Setting

The UK, from 2002 to 2016.

Data sources and participants

Data were from the tobacco industry commercial literature and retail tobacco sales data (Nielsen, New York, NY, USA). Participants were a longitudinal cohort (with replenishment) of smokers and ex-smokers from 10 surveys of the International Tobacco Control Policy Evaluation Project (around 1500 participants per survey).

Main outcome measures

(1) Tobacco industry pricing strategies, (2) sales volumes and prices by segments over time and (3) smokers’ behaviours, including products purchased, sources, brands, consumption, quit attempts, success and sociodemographic differences.

Review methods

Tobacco industry commercial literature was searched for mentions of tobacco products and price segments, with 517 articles extracted.

Results

The tobacco industry increased prices on top of tax increases (overshifting), particularly on premium products, and, recently, the tobacco industry overshifted more on cheap roll-your-own tobacco than on factory-made cigarettes. Increasingly, price rises were from industry revenue generation rather than tax. The tobacco industry raised prices gradually to soften impact; this was less possible with larger tax increases. Budget measures to reduce cheap product availability failed due to new cheap factory-made products, price marking and small packs. In 2014, smokers could buy factory-made (roll-your-own tobacco) cigarettes at real prices similar to 2002. Exclusive roll-your-own tobacco and mixed factory-made cigarettes and roll-your-own tobacco use increased, whereas exclusive factory-made cigarette use decreased, alongside increased cheap product use, rather than quitting. Quitting behaviours were associated with higher taxes. Smokers consumed fewer factory-made cigarettes and reduced roll-your-own tobacco weight over time. Apparent illicit purchasing did not increase. Disadvantaged and dependent smokers struggled with tobacco affordability and were more likely to smoke cheaper products, but disadvantage did not affect quit success.

Limitations

Different for each data set; triangulation increased confidence.

Conclusions

The tobacco industry overshifted taxes and increased revenues, even when tax increases were high. Therefore, tobacco taxes can be further increased to reduce price differentials and recoup public health costs. Government strategies on illicit tobacco appear effective. Large, sudden tax increases would reduce the industry’s ability to manipulate prices, decrease affordability and increase quitting behaviours. More disadvantaged, and dependent, smokers need more help with quitting.

Future work

Assessing the impact of tax changes made since 2014; changing how tax changes are introduced (e.g. sudden intermittent or smaller continuous); and tax changes on tobacco initiation.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 6. See the NIHR Journals Library website for further project information.

Time trends in smoking in Russia in the light of recent tobacco control measures: synthesis of evidence from multiple sources

BACKGROUND

The study aims at identifying long-term trends and patterns of current smoking by age, gender, and education in Russia, including the most recent period from 2008 during which tobacco control policies were implemented, and to estimate the impact on mortality of any reductions in prevalence. We present an in-depth analysis based on an unprecedentedly large array of survey data.

METHODS

We examined pooled micro-data on smoking from 17 rounds of the Russian Longitudinal Monitoring Study of 1996-2016, 11 other surveys conducted in Russia in 1975-2017, and two comparator surveys from England and the USA. Standardization by age and education, regression and meta-analysis were used to estimate trends in the prevalence of current smoking by gender, age, and educational patterns.

RESULTS

From the mid-1970s to the mid-2000s smoking prevalence among men was relatively stable at around 60%, after which time prevalence declined in every age and educational group. Among women, trends in smoking were more heterogeneous. Prevalence more than doubled above the age of 55 years from very low levels (< 5%). At younger ages, there were steep increases until the mid-2000s after which prevalence has declined. Trends differed by educational level, with women in the lowest educational category accounting for most of the long-term increase. We estimate that the decline in male smoking may have contributed 6.2% of the observed reduction in cardiovascular deaths among men in the period 2008-16.

CONCLUSIONS

The implementation of an effective tobacco control strategy in Russia starting in 2008 coincided with a decline in smoking prevalence among men from what had been stable, high levels over many decades regardless of age and education. Among women, the declines have been more uneven, with young women showing recent downturns, while the smoking prevalence in middle age has increased, particularly among those with minimal education. Among men, these positive changes will have made a small contribution to the reduction in mortality seen in Russia since 2005.

Advertising Restrictions and Market Concentration in the Cigarette Industry: A Cross-Country Analysis

There has been a large increase in the adoption of tobacco advertising restrictions worldwide over the last two decades. Much of the literature studies their direct effect on cigarette demand. This paper investigates the indirect effect of advertising restrictions by evaluating the effect of the policies on the degree of concentration in the tobacco market. By using the variation between countries in timing of adoption of advertising restrictions, I estimate difference-in-difference models to examine the effect of an advertising ban on market-concentration, as measured by HHI. I find that advertising bans lead to an increase in market-concentration: HHI increased by 0.06 points for countries that adopted a ban between 2001 and 2017 conditional on trade and socio-economic characteristics, representing a 13% increase with respect to the mean (0.44). The effect is higher in developing countries (0.08 points increase). Further, I find that 'comprehensive' restrictions have a stronger impact on concentration, and 'limited' restrictions have little or no impact. These findings point to an important trade-off for policymakers: on one hand, advertising restrictions are likely to reduce consumption of cigarettes; on the other hand, due to an increase in market-concentration, they may be giving more power to tobacco companies.

Tobacco industry data on illicit tobacco trade: a systematic review of existing assessments

OBJECTIVE

To examine the quality of tobacco industry-funded data on the illicit tobacco trade (ITT) through a systematic review of existing assessments of industry-funded data on ITT.

DATA SOURCES

Papers and reports assessing tobacco industry-funded data on ITT were obtained via searches of 8 academic databases, Google searches and correspondence with ITT experts.

STUDY SELECTION

Inclusion criteria identified 35 English-language papers containing an original assessment of tobacco industry-funded data.

DATA EXTRACTION

Using a coding framework, information was extracted from the assessments regarding the quality of tobacco industry data. Documents were second-coded, achieving 94% intercoder reliability with all disagreements resolved.

DATA SYNTHESIS

Of the 35 assessments reviewed, 31 argued that tobacco industry estimates were higher than independent estimates. Criticisms identified problems with data collection (29), analytical methods (22) and presentation of results (21), which resulted in inflated ITT estimates or data on ITT that were presented in a misleading manner. Lack of transparency from data collection right through to presentation of findings was a key issue with insufficient information to allow replication of the findings frequently cited.

CONCLUSIONS

Tobacco industry data on ITT are not reliable. At present, the tobacco industry continues to fund and disseminate ITT research through initiatives such as PMI IMPACT. If industry data on ITT cannot meet the standards of accuracy and transparency set by high-quality research publications, a solution may be to tax tobacco companies and administer the resulting funds to experts, independent of the tobacco industry, who use previously developed reliable models for measuring ITT.

The US Cigarette Industry: An Economic and Marketing Perspective

Objectives

Tobacco company conduct has been a central concern in tobacco control. Nevertheless, the public health community has not taken full advantage of the large economics and marketing literature on market competition in the cigarette industry.

Methods

We conducted an unstructured narrative review of the economics and marketing literature using an antitrust framework that considers: 1) market; definition, 2) market concentration; 3) entry barriers; and 4) firm conduct.

Results

Since the 1960s, U.S. cigarette market concentration has increased primarily due to mergers and growth in the Marlboro brand. Entry barriers have included brand proliferation, slotting allowance contracts with retailers and government regulation. While cigarette sales have declined, established firms have used coordinated price increases, predatory pricing and price discrimination to sustain their market power and profits.

Conclusions

Although the major cigarette firms have exercised market power to increase prices and profits, the market could be radically changing, with consumers more likely to use several different types of tobacco products rather than just smoking a single cigarette brand. Better understanding of the interaction between market structure and government regulation can help develop effective policies in this changing tobacco product market.

Tobacco industry's elaborate attempts to control a global track and trace system and fundamentally undermine the Illicit Trade Protocol

BACKGROUND

The Illicit Trade Protocol (ITP) requires a global track and trace (T&T) system to reduce tobacco smuggling. Given the tobacco industry's (TI) historical involvement in tobacco smuggling, it stipulates that T&T 'shall not be performed by or delegated to the tobacco industry'. This paper explores the rationale for & nature of the TI's effors to influence the ITP & its T&T system.

METHODS

Analysis of leaked TI documents and publicly available data; ,investigation of front groups, trademark and patent ownership.

FINDINGS

Growing & diverse sources of evidence indicate that the TI remains involved in tobacco smuggling and that TI cigarettes account for around two-thirds of the illicit cigarette market. The TI therefore has a vested interest in controlling the global T&T system aimed to curtail this behaviour. To this end, Philip Morris International (PMI) adapted its pack marker system, Codentify, to meet T&T requirements, licensed it for free to its three major competitors who then collectively promoted it to governments using front groups and third parties including companies claiming to be independent despite clear TI links. PMI also sought to suggest Codentify was independent by selling some parts of its intellectual property on Codentify while retaining others, leaving a complex web of shared interests. In Africa, British American Tobacco used payments to obtain data suggesting its smaller competitor companies were evading taxes and secure influence with tax authorities. Regulatory capture has been enhanced by a public relations effort involving TI funding for conferences, training, research, and international police and anti-corruption organisations. Collectively this has created public messaging and a powerful network of organisations supportive of the TI's misleading postion on illicit.

CONCLUSIONS

Governments should assume the TI seeks to control T&T systems in order to avoid scrutiny and minimise excise tax payments and that any T&T system based on Codentify, on intellectual property currently or previously owned by the TI, or being promoted or implemented by companies with TI links, is incompatible with the ITP and would not serve to reduce illicit trade.

'Greenwashing' tobacco products through ecological and social/equity labelling: A potential threat to tobacco control

There has been significant growth in ecological/environmental labelling of products and services internationally in recent years. Such efforts have become an integral element of the marketing strategies used by many firms. Concerns have been raised, however, that for some companies, this is little more than 'greenwashing', i.e. a cynical attempt to boost sales without any meaningful underlying sensitivity or change, in practice. Given the extremely negative track record of the global tobacco industry (Big Tobacco), it is essential that health policy makers and anti-smoking campaigners closely monitor this industry's attempts to exploit both growing environmental concerns among consumers and gaps in legislation. Although there is relatively strong legislation in some countries, to prohibit suggestions that cigarettes may be environment friendly, a further tightening of legislation is required.

The prevalence of illicit cigarette consumption and related factors in Turkey

Background

The tobacco industry claims that high cigarette taxes drive illicit trade and that governments should therefore not increase tobacco tax because it will increase the level of illicit trade. This study examines illicit cigarette consumption in Turkey after a tobacco tax increase and its related factors.

Method

This national cross-sectional survey was conducted in March-June 2013 and 9717 people aged ≥18 years participated in the interviewer-administered survey. Smokers were asked to show their last used cigarette pack to the interviewers and price paid for their cigarettes. Factors associated with smoking cigarettes with a tobacco tax stamp and paying ≥5 TL (Turkish lira) for a pack of cigarettes were analysed with logistic regression.

Results

Among the observed cigarette packs, 12.1% did not have the Turkish tax stamp. More illicit cigarettes were observed in the East region than in other regions (p<0.001). The reported average amount paid for a pack of cigarettes was €2.12 (€2.15 for men and €1.97 for women, p<0.001). The amount paid for cigarettes with a tax stamp (€2.15) was higher than the amount paid for cigarettes without tax stamp (€1.08) (per cigarette pack) (p<0.001).

Conclusion

Just over 1 in 10 smokers (12%) had an illicit cigarette pack about 5 months after the final tax increase; this was most common in the East region of Turkey. Estimates are comparable to those in previous studies and do not indicate that an increase occurred in the prevalence of illicit cigarette use compared with before the tobacco tax increase.

Death and Taxes: The framing of the causes and policy responses to the illicit tobacco trade in Canadian newspapers

The illicit tobacco trade accounts for 10% of the global cigarette market and results in US$31 billion in lost tax revenues annually. Despite legal prosecution of tobacco companies, and the introduction of new policy responses, the trade has reached an all-time high. Previous research documents how transnational tobacco companies have sought to influence government responses to the illicit trade in various countries through multiple means, including influencing of news media framing. This paper extends this analysis to Canada where the illicit trade is particularly problematic in scale and political complexity. Articles in Canadian newspapers, published from 2010-2015, were systematically searched (n=177) and analyzed to identify dominant frames, frame sponsors and policy positions related to the illicit tobacco trade. The results show that the most common frames present the issue in ways favourable to the industry. The most common non-governmental sponsors of these frames frequently have links to the tobacco industry, which are rarely disclosed. Findings indicate the need for Canadian media to be critical in its use of data sources amid industry efforts to shape public policy, and the importance of reframing policy discussions in public health terms based on independent evidence.

Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: a systematic analysis from the Global Burden of Disease Study 2015

BACKGROUND

The scale-up of tobacco control, especially after the adoption of the Framework Convention for Tobacco Control, is a major public health success story. Nonetheless, smoking remains a leading risk for early death and disability worldwide, and therefore continues to require sustained political commitment. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, and national progress toward achieving smoking-related targets can be assessed.

METHODS

We synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimates of daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed 38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured by disability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohort to better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed out changes in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smoking prevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using the Socio-demographic Index (SDI).

FINDINGS

Worldwide, the age-standardised prevalence of daily smoking was 25·0% (95% uncertainty interval [UI] 24·2-25·7) for men and 5·4% (5·1-5·7) for women, representing 28·4% (25·8-31·1) and 34·4% (29·4-38·6) reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualised rates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countries had significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] and Azerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11·5% of global deaths (6·4 million [95% UI 5·7-7·0 million]) were attributable to smoking worldwide, of which 52·2% took place in four countries (China, India, the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries and territories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followed similar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for female smokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex and SDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smoking-attributable DALYs in low-SDI to middle-SDI geographies between 2005 and 2015.

INTERPRETATION

The pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking's global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, and adequately implemented and enforced policies, which might in turn require global and national levels of political commitment beyond what has been achieved during the past 25 years.

FUNDING

Bill & Melinda Gates Foundation and Bloomberg Philanthropies.

The globalisation strategies of five Asian tobacco companies: a comparative analysis and implications for global health governance

The global tobacco industry, from the 1960s to mid 1990s, saw consolidation and eventual domination by a small number of transnational tobacco companies (TTC). This paper draws together comparative analysis of five case studies in the special issue on 'The Emergence of Asian Tobacco Companies: Implications for Global Health Governance.' The cases suggest that tobacco industry globalisation is undergoing a new phase, beginning in the late 1990s, with the adoption of global business strategies by five Asian companies. The strategies were prompted foremost by external factors, notably market liberalisation, competition from TTCs and declining domestic markets. State protection and promotion enabled the industries in Japan, South Korea and China to rationalise their operations ahead of foreign market expansion. The TTM and TTL will likely remain domestic or perhaps regional companies, JTI and KT&G have achieved TTC status, and the CNTC is poised to dwarf all existing companies. This global expansion of Asian tobacco companies will increase competition which, in turn, will intensify marketing, exert downward price pressures along the global value chain, and encourage product innovation. Global tobacco control requires fuller understanding of these emerging changes and the regulatory challenges posed by ongoing globalisation.

The globalisation strategies of five Asian tobacco companies: An analytical framework

With 30% of the world’s smokers, two million deaths annually from tobacco use, and rising levels of tobacco consumption, the Asian region is recognised as central to the future of global tobacco control. There is less understanding, however, of how Asian tobacco companies with regional and global aspirations are contributing to the global burden of tobacco-related disease and death. This introductory article sets out the background and rationale for this special issue on ‘The Emergence of Asian Tobacco Companies: Implications for Global Health Governance’. The article discusses the core questions to be addressed and presents an analytical framework for assessing the globalisation strategies of Asian tobacco firms. The article also discusses the selection of the five case studies, namely as independent companies in Asia which have demonstrated concerted ambitions to be a major player in the world market.

Tobacco industry globalization and global health governance: towards an interdisciplinary research agenda

Shifting patterns of tobacco production and consumption, and the resultant disease burden worldwide since the late twentieth century, prompted efforts to strengthen global health governance through adoption of the Framework Convention on Tobacco Control. While the treaty is rightfully considered an important achievement, to address a neglected public health issue through collective action, evidence suggests that tobacco industry globalization continues apace. In this article, we provide a systematic review of the public health literature and reveal definitional and measurement imprecision, ahistorical timeframes, transnational tobacco companies and the state as the primary units and levels of analysis, and a strong emphasis on agency as opposed to structural power. Drawing on the study of globalization in international political economy and business studies, we identify opportunities to expand analysis along each of these dimensions. We conclude that this expanded and interdisciplinary research agenda provides the potential for fuller understanding of the dual and dynamic relationship between the tobacco industry and globalization. Deeper analysis of how the industry has adapted to globalization over time, as well as how the industry has influenced the nature and trajectory of globalization, is essential for building effective global governance responses. This article is published as part of a thematic collection dedicated to global governance.

Multimorbidity and the inequalities of global ageing: a cross-sectional study of 28 countries using the World Health Surveys

BACKGROUND

Multimorbidity defined as the "the coexistence of two or more chronic diseases" in one individual, is increasing in prevalence globally. The aim of this study is to compare the prevalence of multimorbidity across low and middle-income countries (LMICs), and to investigate patterns by age and education, as a proxy for socio-economic status (SES).

METHODS

Chronic disease data from 28 countries of the World Health Survey (2003) were extracted and inter-country socio-economic differences were examined by gross domestic product (GDP). Regression analyses were applied to examine associations of education with multimorbidity by region adjusted for age and sex distributions.

RESULTS

The mean world standardized multimorbidity prevalence for LMICs was 7.8 % (95 % CI, 7.79 % - 7.83 %). In all countries, multimorbidity increased significantly with age. A positive but non-linear relationship was found between country GDP and multimorbidity prevalence. Trend analyses of multimorbidity by education suggest that there are intergenerational differences, with a more inverse education gradient for younger adults compared to older adults. Higher education was significantly associated with a decreased risk of multimorbidity in the all-region analyses.

CONCLUSIONS

Multimorbidity is a global phenomenon, not just affecting older adults in HICs. Policy makers worldwide need to address these health inequalities, and support the complex service needs of a growing multimorbid population.

A Systematic Review of Tobacco Smoking Prevalence and Description of Tobacco Control Strategies in Sub-Saharan African Countries; 2007 to 2014

Objective

To systematically review current smoking prevalence among adults in sub-Saharan Africa from 2007 to May 2014 and to describe the context of tobacco control strategies in these countries.

Data Sources

Five databases, Medline, Embase, Africa-wide Information, Cinahl Plus, and Global Health were searched using a systematic search strategy. There were no language restrictions.

Study Selection

26 included studies measured current smoking prevalence in nationally representative adult populations in sub-Saharan African countries.

Data Extraction

Study details were independently extracted using a standard datasheet. Data on tobacco control policies, taxation and trends in prices were obtained from the Implementation Database of the WHO FCTC website.

Results

Studies represented 13 countries. Current smoking prevalence varied widely ranging from 1.8% in Zambia to 25.8% in Sierra Leone. The prevalence of smoking was consistently lower in women compared to men with the widest gender difference observed in Malawi (men 25.9%, women 2.9%). Rwanda had the highest prevalence of women smokers (12.6%) and Ghana had the lowest (0.2%). Rural, urban patterns were inconsistent. Most countries have implemented demand-reduction measures including bans on advertising, and taxation rates but to different extents.

Conclusion

Smoking prevalence varied widely across sub-Saharan Africa, even between similar country regions, but was always higher in men. High smoking rates were observed among countries in the eastern and southern regions of Africa, mainly among men in Ethiopia, Malawi, Rwanda, and Zambia and women in Rwanda and rural Zambia. Effective action to reduce smoking across sub-Saharan Africa, particularly targeting population groups at increased risk remains a pressing public health priority.

Towards a comprehensive global approach to prevention and control of NCDs

BACKGROUND

The "25×25" strategy to tackle the global challenge of non-communicable diseases takes a traditional approach, concentrating on a few diseases and their immediate risk factors.

DISCUSSION

We propose elements of a comprehensive strategy to address NCDs that takes account of the evolving social, economic, environmental and health care contexts, while developing mechanisms to respond effectively to local patterns of disease. Principles that underpin the comprehensive strategy include: (a) a balance between measures that address health at the individual and population level; (b) the need to identify evidence-based feasible and effective approaches tailored to low and middle income countries rather than exporting questionable strategies developed in high income countries; (c) developing primary health care as a universal framework to support prevention and treatment; (d) ensuring the ability to respond in real time to the complex adaptive behaviours of the global food, tobacco, alcohol and transport industries; (e) integrating evidence-based, cost-effective, and affordable approaches within the post-2015 sustainable development agenda; (f) determination of a set of priorities based on the NCD burden within each country, taking account of what it can afford, including the level of available development assistance; and (g) change from a universal "one-size fits all" approach of relatively simple prevention oriented approaches to more comprehensive multi-sectoral and development-oriented approaches which address both health systems and the determinants of NCD risk factors.

SUMMARY

The 25×25 is approach is absolutely necessary but insufficient to tackle the the NCD disease burden of mortality and morbidity. A more comprehensive approach is recommended.

Trade and investment liberalization and Asia's noncommunicable disease epidemic: a synthesis of data and existing literature

BACKGROUND

Trade and investment liberalization (trade liberalization) can promote or harm health. Undoubtedly it has contributed, although unevenly, to Asia's social and economic development over recent decades with resultant gains in life expectancy and living standards. In the absence of public health protections, however, it is also a significant upstream driver of non-communicable diseases (NCDs) including cardiovascular disease, cancer and diabetes through facilitating increased consumption of the 'risk commodities' tobacco, alcohol and ultra-processed foods, and by constraining access to NCD medicines. In this paper we describe the NCD burden in Asian countries, trends in risk commodity consumption and the processes by which trade liberalization has occurred in the region and contributed to these trends. We further establish pressing questions for future research on strengthening regulatory capacity to address trade liberalization impacts on risk commodity consumption and health.

METHODS

A semi-structured search of scholarly databases, institutional websites and internet sources for academic and grey literature. Data for descriptive statistics were sourced from Euromonitor International, the World Bank, the World Health Organization, and the World Trade Organization.

RESULTS

Consumption of tobacco, alcohol and ultra-processed foods was prevalent in the region and increasing in many countries. We find that trade liberalization can facilitate increased trade in goods, services and investments in ways that can promote risk commodity consumption, as well as constrain the available resources and capacities of governments to enact policies and programmes to mitigate such consumption. Intellectual property provisions of trade agreements may also constrain access to NCD medicines. Successive layers of the evolving global and regional trade regimes including structural adjustment, multilateral trade agreements, and preferential trade agreements have enabled transnational corporations that manufacture, market and distribute risk commodities to increasingly penetrate and promote consumption in Asian markets.

CONCLUSIONS

Trade liberalization is a significant driver of the NCD epidemic in Asia. Increased participation in trade agreements requires countries to strengthen regulatory capacity to ensure adequate protections for public health. How best to achieve this through multilateral, regional and unilateral actions is a pressing question for ongoing research.

Tobacco industry manipulation of data on and press coverage of the illicit tobacco trade in the UK

BACKGROUND

In the UK, transnational tobacco companies (TTCs) have been arguing that levels of illicit trade are high and increasing and will rise further if standardised packaging is implemented. This paper examines trends in and accuracy of media reporting of, and industry data on, illicit tobacco in the UK.

METHODS

Quantification of the volume, nature and quality of press articles citing industry data on illicit tobacco in UK newspapers from March 2008 to March 2013. Examination of published TTC data on illicit, including a comparison with independent data and of TTC reporting of Her Majesty's Revenue and Customs data on illicit.

RESULTS

Media stories citing industry data on illicit tobacco began in June 2011, 2 months after the Tobacco Control Plan for England, which heralded standardised packaging, was published. The majority of data cited are based on industry Empty Pack Surveys for which no methodology is available. For almost all parts of the country where repeat data were cited in press stories, they indicated an increase, often substantial, in non-domestic/illicit cigarettes that is not supported by independent data. Similarly, national data from two published industry sources show a sudden large increase in non-domestic product between 2011 and 2012. Yet the methodology of one report changes over this period and the other provides no published methodology. In contrast, independent data show steady declines in non-domestic and illicit cigarette penetration from 2006 to 2012 and either a continued decline or small increase to 2013.

CONCLUSIONS

Industry claims that use of Non-UK Duty Paid/illicit cigarettes in the UK is sharply increasing are inconsistent with historical trends and recent independent data. TTCs are exaggerating the threat of illicit tobacco by commissioning surveys whose methodology and validity remain uncertain, planting misleading stories and misquoting government data. Industry data on levels of illicit should be treated with extreme caution.

Measuring Armenia's progress on the Tobacco Control Scale: an evaluation of tobacco control in an economy in transition, 2005-2009

OBJECTIVES

This study aimed to measure the 5-year progress in the implementation of WHO Framework Convention on Tobacco Control (FCTC) in Armenia by applying the Tobacco Control Scale, a rapid assessment tool developed to assess the strength of tobacco control policies in Europe.

SETTING

Armenia, an economy in transition, has extreme smoking rates among men (62.5%) despite acceding to FCTC in 2004. However, little research has been carried out to evaluate Armenia's progress in tobacco control.

METHODS

The Tobacco Control Scale total score was estimated for Armenia using the original methodology; however, a different source of data was used in estimating the subscores on tobacco price and tobacco control spending.

RESULTS

Armenia's total score on Tobacco Control Scale has considerably improved from 2005 to 2009, mostly due to larger health warnings and advertising ban, and increased public spending on tobacco control. The scores for smoke-free public places, advertising ban, health warnings and treatment categories were below the European average in 2005 and 2007, while the price score was higher. Neither total tobacco control score nor any of its components showed a significant predictive value in a simple regression analysis using the total score and subscores as predictors for log-transformed per capita tobacco consumption.

CONCLUSIONS

Higher than the European average price score for Armenia cannot be explained by the concept of affordability alone and may reflect a measurement error due to peculiarities of transition economies. The applicability of the Tobacco Control Scale could be limited to countries with mature economies, but not to transition countries such as Armenia with different social, political and economic environment. The scale modification, such as an adjustment for the policy enforcement and the effectiveness of public tobacco control spending along with alternative measures of affordability would be warranted to enhance its applicability in low-income and middle-income countries.

Tobacco control efforts in Europe

Smoking is prevalent across Europe, but the severity and stage of the smoking epidemic, and policy responses to it, vary substantially between countries. Much progress is now being made in prohibition of paid-for advertising and in promotion of smoke-free policies, but mass media campaigns are widely underused, provision of services for smokers trying to quit is generally poor, and price policies are undermined by licit and illicit cheap supplies. Monitoring of prevalence is inadequate in many countries, as is investment in research and capacity to address this largest avoidable cause of death and disability across Europe. However, grounds for optimism are provided by progress in implementation of the WHO Framework Convention on Tobacco Control, and in the development of a new generation of nicotine-containing devices that could enable more widespread adoption of harm-reduction strategies. The effect of commercial vested interests has been and remains a major barrier to progress.

Tobacco control in the Russian Federation--a policy analysis

BACKGROUND

The Russian Federation (Russia) has one of the highest smoking rates in the world. The purpose of this study is to analyze past and current trends of the tobacco epidemic in the Russian Federation, review current tobacco control policy responses, and identify areas of opportunity for policy priorities.

METHODS

We used a policy triangle as analytical framework to examine content, context, and processes of Russian tobacco control policy. The analysis was based on secondary data on supply and demand sides of the Russian tobacco epidemic, tobacco-related economic and health effects during Russia's economic transition, and compliance of Russian tobacco policy with international standards and regulations.

RESULTS

Tobacco-promoting strategies have specifically targeted women and youth. Russia's approval of a "National Tobacco Control Concept" and draft for a comprehensive tobacco control bill increasingly align national legislature with the WHO Framework Convention on Tobacco Control (FCTC). However, several structural and cultural factors represent substantial barriers to the policy process. The influence of transnational tobacco companies on policy processes in Russia has so far impeded a full implementation of the FCTC mandates.

CONCLUSIONS

Several strategies have been identified as having the potential to reduce the prevalence of tobacco use in Russia and decrease tobacco-related national health and economic burden: adjusting national tobacco policy by raising tobacco tax from the current lowest level in Europe to at least 70%; consequent enforcement of a complete smoking ban in public places; marketing restrictions; and smoking cessation interventions integrated into primary care. Russia's tobacco control efforts need to target women and youths specifically to efficiently counter industry efforts.

Are transnational tobacco companies' market access strategies linked to economic development models? A case study of South Korea

Transnational tobacco companies (TTCs) have used varied strategies to access previously closed markets. Using TTCs' efforts to enter the South Korean market from the late 1980s as a case study, this article asks whether there are common patterns in these strategies that relate to the broader economic development models adopted by targeted countries. An analytical review of the existing literature on TTCs' efforts to access emerging markets was conducted to develop hypotheses relating TTCs' strategies to countries' economic development models. A case study of Korea was then undertaken based on analysis of internal tobacco industry documents. Findings were consistent with the hypothesis that TTCs' strategies in Korea were linked to Korea's export-oriented economic development model and its hostile attitude towards foreign investment. A fuller understanding of TTCs' strategies for expansion globally can be derived by locating them within the economic development models of specific countries or regions. Of foremost importance is the need for governments to carefully balance economic and public health policies when considering liberalisation.

Creating demand for foreign brands in a 'home run' market: tobacco company tactics in South Korea following market liberalisation

OBJECTIVE

To analyse the tactics transnational tobacco companies (TTCs) used to increase market share in South Korea after market liberalisation in 1988, and the subsequent impact of TTCs' activities on the domestic industry and ultimately public health.

METHODS

Internal tobacco industry documents were searched iteratively and analysed by keyword related to strategies for increasing market share in Korea since liberalisation.

RESULTS

Following market liberalisation, TTCs faced entrenched cultural and institutional barriers in Korea which hindered increased sales of cigarette imports. TTCs identified population groups more favourably inclined towards imported brands, developed new distribution channels and used promotional activities targeting these groups. The growth in market share by TTCs suggests that these activities were successful at challenging the Korea Tobacco & Ginseng Corporation (KTGC) monopoly. In response, KTGC shifted to a proactive marketing approach and adopted strategies similar to TTCs. This, in turn, made the Korean market highly competitive. Findings show that, after market liberalisation, there was an upward trend in cigarette consumption and smoking prevalence among the targeted population groups, notably youth and young women.

CONCLUSIONS

Governments engaging in trade negotiations that may lead to the opening of domestic tobacco markets need a fuller understanding of previous industry activities for expanding into emerging markets as well as how the domestic industry can change accordingly. To protect public health, the adoption of comprehensive tobacco control measures, guided by WHO Framework Convention on Tobacco Control, are needed as part of such negotiations.

Price and tax measures and illicit trade in the framework convention on tobacco control: what we know and what research is required

INTRODUCTION

Article 6 of the Framework Convention on Tobacco Control commits Parties to use tax and price policies to reduce tobacco use, whereas Article 15 commits Parties to implement measures to eliminate the illicit trade in tobacco products. This paper identifies research gaps/needs, especially in low- and middle-income countries, which, if adequately addressed, would help in implementing Articles 6 and 15.

METHODS

Based on a recent comprehensive review on the impact of tax and price on tobacco consumption and a summary of reviews and narratives about the illicit tobacco market, research gaps are identified.

RESULTS

Countries have highly diverse research needs, depending on the stage of the tobacco epidemic, previous research and data availability, and making a ranking of research needs infeasible. Broad issues for further research are the following: (1) monitoring tobacco consumption, prices, and taxes, (2) assessing the effectiveness of the tax structure in generating revenue and reducing tobacco use, (3) strengthening the tax administration system in order to reduce tax evasion and tax avoidance, (4) improving our understanding of the political economy of tobacco tax policy, and (5) employing a multidisciplinary approach to assessing the magnitude of illicit tobacco trade.

CONCLUSIONS

At a technical level, the case for increasing excise taxes to improve public health and increase government revenue is easily made, but the political and policy environment is often not supportive. In order to effectively impact policy, the required approach would typically make use of rigorous economic techniques, and be cognizant of the political economy of raising excise taxes.

Socioeconomic implications of tobacco use in Ghana

INTRODUCTION

Country-level evidence from Africa on the prevalence of tobacco use and the role played by both demographic and socioeconomic factors, as influences on the use of tobacco products, is sparse. This paper analyzes the determinants of tobacco use in Ghana and explores the association between tobacco use and poverty in the country.

METHODS

Data from the 2008 Ghana Demographic and Health Survey, a nationally representative survey of households (n = 12,323), were used to generate descriptive statistics and characterize tobacco use in the country. A logistic regression model was used to evaluate the relationships between tobacco use and age, place of residence, region, education status, wealth, marital status, alcohol use, and whether the person has children. Unadjusted and adjusted odds ratios were calculated for tobacco users and nonusers on the likelihood of their purchase of selected commodities indicative of living standards.

RESULTS

Tobacco use was significantly higher among those living in poverty stricken regions, those with less education, lower levels of wealth, parents, and alcohol users. Tobacco use was significantly higher among men (7%) than women (0.4%), and it increased to a peak age of 41.4 years before it declined. Using tobacco was also associated with a lower likelihood of purchasing health insurance.

DISCUSSION

Tobacco use is inextricably related to poverty in Ghana. Policies should be formulated to target populations and regions with higher tobacco prevalence to combat both poverty and tobacco use simultaneously.

The vector of the tobacco epidemic: tobacco industry practices in low and middle-income countries

PURPOSE

To understand transnational tobacco companies' (TTCs) practices in low and middle-income countries which serve to block tobacco-control policies and promote tobacco use.

METHODS

Systematic review of published research on tobacco industry activities to promote tobacco use and oppose tobacco-control policies in low and middle-income countries.

RESULTS

TTCs' strategies used in low and middle-income countries followed four main themes-economic activity; marketing/promotion; political activity; and deceptive/manipulative activity. Economic activity, including foreign investment and smuggling, was used to enter new markets. Political activities included lobbying, offering voluntary self-regulatory codes, and mounting corporate social responsibility campaigns. Deceptive activities included manipulation of science and use of third-party allies to oppose smoke-free policies, delay other tobacco-control policies, and maintain support of policymakers and the public for a pro-tobacco industry policy environment. TTCs used tactics for marketing, advertising, and promoting their brands that were tailored to specific market environments. These activities included direct and indirect tactis, targeting particular populations, and introducing new tobacco products designed to limit marketing restrictions and taxes, maintain the social acceptability of tobacco use, and counter tobacco-control efforts.

CONCLUSIONS

TTCs have used similar strategies in high-income countries as these being described in low and middle-income countries. As required by FCTC Article 5.3, to counter tobacco industry pressures and to implement effective tobacco-control policies, governments and health professionals in low and middle-income countries should fully understand TTCs practices and counter them.

Cigarette pack labelling in 12 countries at different levels of economic development

With increasing restrictions on cigarette marketing, the cigarette pack itself has become a main means of marketing. We describe a method to examine cigarette labelling and use it to evaluate packs collected from 12 countries at different stages of economic development. Health warnings were present on all 115 packs of cigarettes examined, but were on the front and back panels of only 68 per cent. Promotional labels were widespread, found on packs from all countries and more numerous (although not necessarily larger) than health warning labels in 10 of the 12 countries. Deceptive terms such as 'light' and 'mild' were observed on 42 per cent of all packs examined. The simple method described here can be used to compare cigarette labelling and potentially evaluate and track the implementation of cigarette labelling policy. We found health warning legislation poorly enforced and cigarette packs widely used to promote smoking and deceive smokers about health risks. The findings underline the need for generic (plain) packaging.

Is income or employment a stronger predictor of smoking than education in economically less developed countries? A cross-sectional study in Hungary

Background

In developed European countries in the last phase of the smoking epidemic, education is a stronger predictor of smoking than income or employment. We examine whether this also applies in economically less developed countries.

Methods

Data from 7218 respondents in the 25-64 age group came from two National Health Interview Surveys conducted in 2000 and 2003 in Hungary. Independent effects of educational level, income and employment status were studied in relation to smoking prevalence, initiation and continuation for all age groups combined and separately for 25-34, 35-49 and 50-64 years old. Absolute levels were evaluated by using age-standardized prevalence rates. Relative differences were assessed by means of logistic regression.

Results

Education and income, but not employment, were associated with equally large differences in smoking prevalence in Hungary in the 25-64 age group. Among men, smoking initiation was related to low educational level, whereas smoking continuation was related to low income. Among women, low education and low income were associated with both high initiation and high continuation rates. Considerable differences were found between the age groups. Inverse social gradients were generally strongest in the youngest age groups. However, smoking continuation among men had the strongest association with low income for the middle-aged group.

Conclusions

Patterns of inequalities in smoking in Hungary can be best understood in relation to two processes: the smoking epidemic, and the additional effects of poverty. Equity orientated tobacco control measures should target the low educated to prevent their smoking initiation, and the poor to improve their cessation rates.

A review of the impacts of tobacco industry privatisation: Implications for policy

State-owned tobacco companies, which still account for 40% of global cigarette production, face continued pressure from, among others, the International Monetary Fund (IMF), to be privatised. This review of available literature on tobacco industry privatisation suggests that any economic benefits of privatisation may be lower than supposed, because private owners avoid competitive tenders (thus underpaying for assets), negotiate lengthy tax holidays and are complicit in the smuggling of cigarettes to avoid import and excise duties. It outlines how privatisation leads to increased marketing, more effective distribution and lower prices, creating additional demand for cigarettes among new and existing smokers, leading to increased cigarette consumption, higher smoking prevalence and lower age of smoking initiation. Privatisation also weakens tobacco control because private owners, in their drive for profits, lobby aggressively against effective policies and ignore or overturn existing policies. This evidence suggests that further tobacco industry privatisation is likely to increase smoking and that instead of transferring assets from state to private ownership, alternative models of supply should be explored.

The social determinants of adolescent smoking in Russia in 2004

OBJECTIVES

To determine the prevalence of adolescent smoking in the Russian Federation and examine what factors are associated with it.

METHODS

Data were drawn from Round 13 of the Russia Longitudinal Monitoring Survey (RLMS) carried out in 2004. The sample consists of 815 adolescents (430 boys, 385 girls) aged 14-17 years who answered questions about their health behaviours.

RESULTS

Smoking was more prevalent among boys than girls (26.1 vs. 5.7%). Maternal smoking and adolescent alcohol use were associated with smoking among both sexes. The self-assessment of one's socioeconomic position as unfavourable was associated with girls' smoking, while living in a disrupted family, physical inactivity and having a low level of self-esteem were predictive of boys' smoking.

CONCLUSIONS

The family environment appears to be an important determinant of adolescent smoking in Russia. In particular, boys and girls may be modelling the negative health behaviour lifestyles of their parents, with unhealthy behaviours clustering. Efforts to reduce adolescent smoking in Russia must address the negative effects emanating from the parental home whilst also addressing associated behaviours such as alcohol use.

"The lobbying strategy is to keep excise as low as possible" - tobacco industry excise taxation policy in Ukraine

Background

Tobacco taxes are one of the most effective ways to reduce tobacco use. Transnational tobacco companies (TTCs) claim they wish to develop and secure excise systems that benefit both governments and the profitability of the companies themselves. The objective of the paper is to use the case of Ukraine, with its inconsistent history of excise tax changes in 1992-2008, to explore tobacco industry taxation strategies and tactics, and their implications for governmental revenues.

Methods

Details of tobacco industry policy on tobacco taxation in Ukraine were obtained by searching tobacco industry internal documents and various published reports.

Results

Even before entering the market in Ukraine, TTCs had made efforts to change the excise system in the country. In 1993-1994, TTCs lobbied the Ukrainian Government, and succeeded in achieving a lowering in tobacco tax. This, however, did not produce revenue increase they promised the Government. In 1996-1998, Ukrainian authorities increased excise several times, ignoring the wishes of TTCs, caused significant growth in revenue. Due to TTCs lobbying activities in 1999-2007 the tax increases were very moderate and it resulted in increased tobacco consumption in Ukraine. In 2008, despite the TTCs position, excise rates were increased twice and it was very beneficial for revenues.

Conclusions

The Framework Convention on Tobacco Control includes provisions both on tobacco taxation policy and on protection of public health policy from vested interests of tobacco industry. This paper provides arguments why tobacco taxation policy should also be protected from vested interests of tobacco industry. TTCs taxation strategy appears to be consistent: keep excise as low as possible. Apparent conflicts between TTCs concerning tax structures often hide their real aim to change tax structures for competing interests without increasing total tax incidence. Governments, that aim to reduce levels of tobacco use, should not allow tobacco companies to influence the development and implementation of tobacco taxation policy.

Reforming sanitary-epidemiological service in Central and Eastern Europe and the former Soviet Union: an exploratory study

BACKGROUND

Public health services in the Soviet Union and its satellite states in Central and Eastern Europe were delivered through centrally planned and managed networks of sanitary-epidemiological (san-epid) facilities. Many countries sought to reform this service following the political transition in the 1990s. In this paper we describe the major themes within these reforms.

METHODS

A review of literature was conducted. A conceptual framework was developed to guide the review, which focused on the two traditional core public health functions of the san-epid system: communicable disease surveillance, prevention and control and environmental health. The review included twenty-two former communist countries in the former Soviet Union (fSU) and in Central and Eastern Europe (CEE).

RESULTS

The countries studied fall into two broad groups. Reforms were more extensive in the CEE countries than in the fSU. The CEE countries have moved away from the former centrally managed san-epid system, adopting a variety of models of decentralization. The reformed systems remain mainly funded centrally level, but in some countries there are contributions by local government. In almost all countries, epidemiological surveillance and environmental monitoring remained together under a single organizational umbrella but in a few responsibilities for environmental health have been divided among different ministries.

CONCLUSIONS

Progress in reform of public health services has varied considerably. There is considerable scope to learn from the differing experiences but also a need for rigorous evaluation of how public health functions are provided.

The International Monetary Fund's effects on global health: before and after the 2008 financial crisis

In April 2009, the G20 countries committed US $750 billion to the International Monetary Fund (IMF), which has assumed a central role in global economic management. The IMF provides loans to financially ailing countries, but with strict conditions, typically involving a mix of privatization, liberalization, and fiscal austerity programs. These loan conditions have been extremely controversial. In principle, they are designed to help countries balance their books. In practice, they often translate into reductions in social spending, including spending on public health and health care delivery. As more countries are being exposed to IMF policies, there is a need to establish what we know and do not know about the IMF's effects on global health. This article introduces a series in which contributors review the evidence on the relationship between the IMF and public health and discuss potential ways to improve the Fund's effects on health. While more evidence is needed for some regions, there is sufficient evidence to indicate that IMF programs have been significantly associated with weakened health care systems, reduced effectiveness of health-focused development aid, and impeded efforts to control tobacco, infectious diseases, and child and maternal mortality. Reforms are urgently needed to prevent the current wave of IMF programs from further undermining public health in financially ailing countries and limiting progress toward the health Millennium Development Goals.

The International Monetary Fund and Tobacco: A Product like Any Other?

The International Monetary Fund (IMF) has promoted the lifting of trade restrictions on tobacco and the privatization of state-owned tobacco industries as part of its loan conditions. Growing evidence shows that tobacco industry privatization stimulates tobacco consumption and smoking prevalence in borrowing countries. Privatized tobacco companies make favorable tobacco control policies a condition of their investment and lobby aggressively against further control measures. This, along with increased efficiency of the private sector, leads to increases in marketing, substantial reductions in excise taxes, drops in cigarette prices, and overall rises in sales of cigarettes. The actions of the IMF have therefore led to substantially greater use of tobacco, a product that kills half of its consumers when used as intended, with little evidence of economic gain.

The social and economic determinants of smoking in Moscow, Russia

BACKGROUND

Despite a high prevalence of smoking for decades, recent research has documented an increase in the rates of both male and female smoking in post-Soviet Russia. As yet, however, little research has taken place on smoking at the subnational level. The current study addresses this deficit by examining smoking in Moscow -- the city that has been at the forefront of the entry into the Russian market of transnational tobacco corporations (TTCs) in the transition period.

METHODS

Data were obtained from the Moscow Health Survey 2004 -- a stratified random sample of 1190 people representative of Moscow's larger population. Information was obtained about subjects' smoking habits and age of smoking initiation.

RESULTS

The prevalence of smoking was high among both men (55.5%) and women (26.9%), with significantly higher rates in the younger age groups. There was also a high prevalence of smoking initiation before age 15 years, especially in the youngest women (18-30 years). Logistic regression analysis showed that respondents' age, binge drinking, locus of control and economic situation were important determinants of smoking.

CONCLUSIONS

Although lifestyle factors seem to underpin the generally high levels of smoking, other things, such as its high prevalence in the younger generations and the factors associated with smoking (locus of control), nevertheless suggest that the TTCs may have played an important role in the spread of smoking in transitional Russia's changing social environment.

Open doorway to truth: legacy of the Minnesota tobacco trial

More than a decade has passed since the conclusion of the Minnesota tobacco trial and the signing of the Master Settlement Agreement (MSA) by 46 US State Attorneys General and the US tobacco industry. The Minnesota settlement exposed the tobacco industry's long history of deceptive marketing, advertising, and research and ultimately forced the industry to change its business practices. The provisions for public document disclosure that were included in the Minnesota settlement and the MSA have resulted in the release of approximately 70 million pages of documents and nearly 20,000 other media materials. No comparable dynamic, voluminous, and contemporaneous document archive exists. Only a few single events in the history of public health have had as dramatic an effect on tobacco control as the public release of the tobacco industry's previously secret internal documents. This review highlights the genesis of the release of these documents, the history of the document depositories created by the Minnesota settlement, the scientific and policy output based on the documents, and the use of the documents in furthering global public health strategies.