Integrating tobacco control into health and development agendas

Tobacco use is one of the major risk factors for non-communicable diseases, with a profound impact on resource-poor low-income and middle-income countries such as India, where tobacco use is high and where socioeconomic as well as health inequalities are rampant. Effective implementation of the Framework Convention on Tobacco Control requires multisectoral efforts that can fructify through integration of tobacco control into broader health and development agendas such as food and water security, environment, the right to education and human rights. The global tobacco control community will need to explore innovative partnerships beyond its traditional confines and build a global coalition that supports tobacco control by partnering with others having convergent concerns on common determinants. A firm political commitment and intersectoral coordination between government and non-government agencies is paramount in order to implement effective tobacco control programmes. Integration of tobacco control into other health and development agendas as described in this paper has the potential to contribute to the achievement of all the eight United Nations Millennium Development Goals. This paper explores why the whole of government should accord a high priority to tobacco control, and how this integration could be achieved.     

Globalisation of tobacco industry influence and new global responses

The globalisation of tobacco marketing, trade, research, and industry influence represents a major threat to public health worldwide. Drawing upon tobacco industry strategy documents prepared over several decades, this paper will demonstrate how the tobacco industry operates as a global force, regarding the world as its operating market by planning, developing, and marketing its products on a global scale. The industry has used a wide range of methods to buy influence and power, and penetrate markets across the world. It has an annual turnover of almost US$400 billion. In contrast, until recently tobacco control lacked global leadership and strategic direction and had been severely underfunded. As part of moving towards a more sustainable form of globalisation, a global enabling environment linked to local actions should focus on the following strategies: global information management; development of nationally and locally grounded action; global regulation, legal instruments, and foreign policy; and establishment of strong partnerships with purpose. As the vector of the tobacco epidemic, the tobacco industry's actions fall far outside of the boundaries of global corporate responsibility. Therefore, global and local actions should not provide the tobacco industry with the two things that it needs to ensure its long term profitability: respectability and predictability.     

Perspectives on the role of the Society for Research on Nicotine and Tobacco in promoting global tobacco research and reducing tobacco harm.

The Society for Research on Nicotine and Tobacco (SRNT) has a critical role to play in advancing tobacco research globally. To date SRNT has sponsored a number of successful initiatives including meetings held by the society's European affiliate, establishment of the Global Network Committee in 1999, and the 2003 and 2005 global tobacco pre-conferences. The most recent SRNT conference was held for the first time outside of North America and attracted over 900 participants from 50 countries. SRNT also has sponsored workshops, provided member scholarships to researchers from low- and middle-income countries, and partnered with the World Health Organization to host www.treatobacco.net. Although these initiatives are impressive, SRNT can further support global tobacco research by (a) working with other organizations to support global tobacco science and policy (this is especially timely given the recent coming into force of the Framework Convention on Tobacco Control), (b) providing more resources including increased funding and access to online journals for those in low- and middle-income countries, (c) increasing the representation of science at world and national tobacco conferences, and (d) expanding the role of the Training Committee to place increased emphasis on mentoring tobacco scientists from low- and middle-income countries. Science will be crucial in addressing the global tobacco pandemic, and SRNT is uniquely positioned to further tobacco science and research capacity on a global basis.     

吸烟行为的动因分析

吸烟是一种理性成瘾行为。从个人角度看，促使其吸烟的现实动因是追求生理快感、调节心理情绪、密切社会交往、增添生活乐趣和实现自我认可。从群体角度看，促使人类吸烟的历史动因主要是航行和人口迁移导致全球扩散，药用和“烟疗百疾”引发使用流行，战争和社会动荡刺激消费增长，贸易和技术变革推动供给创新，文化和艺术关联提升精神影响。吸烟行为具有历史合理性，烟草控制具有价值正当性，以史为鉴，对待烟草问题应避免落入“塔西陀陷阱”，防止良好动机和控烟政策难以落地。      

Tobacco use among youth: a cross country comparison

Methods: The GYTS employs a standard methodology where self administered questionnaires, consisting of a set of core questions, are completed by a representative school based sample of students primarily between the ages of 13–15 years.

Results: Data are presented from 75 sites in 43 countries and the Gaza Strip/West Bank region. Current use of any tobacco product ranges from 62.8% to 3.3%, with high rates of oral tobacco use in certain regions. Current cigarette smoking ranges from 39.6% to less than 1%, with nearly 25% of students who smoke, having smoked their first cigarette before the age of 10 years. The majority of current smokers want to stop smoking and have already tried to quit, although very few students who currently smoke have ever attended a cessation programme. Exposure to advertising is high (75% of students had seen pro-tobacco ads), and exposure to environmental tobacco smoke (ETS) is very high in all countries. Only about half of the students reported that they had been taught in school about the dangers of smoking during the year preceding the survey.

Conclusions: Global youth tobacco use is already widespread throughout the world, but there is great variation among nations. Valid and reliable data on the extent of youth tobacco use, and correlates of use, are essential to plan and evaluate tobacco use prevention programmes. The GYTS has proven the feasibility of an inexpensive, standardised, worldwide surveillance system for youth tobacco use. The GYTS will be expanded to the majority of countries in the next few years, and can serve as a baseline for monitoring and evaluating global and national tobacco control efforts.

     

Opportunities and risks of the proposed FCTC protocol on illicit trade

Illicit trade in tobacco products presents a threat to public health because it undermines the use of tax and price policies, which are among the most effective mechanisms for reducing tobacco consumption. Parties to the WHO Framework Convention on Tobacco Control (FCTC) are in the final stages of negotiating a protocol aimed at strengthening international cooperation in the fight against illicit tobacco trade. While an effective multilateral response to illicit tobacco trade would make a significant contribution to global tobacco control, achieving this through the FCTC forum is challenging. First, while illicit tobacco trade is a health problem, the expertise, experience and capacity needed to combat illicit trade are not traditionally found in health agencies. The development of links with other agencies, both domestic and international, is critical to ensure both an effective response and an efficient use of limited governmental and non-governmental resources. Second, in many parts of the world, the tobacco industry cooperates closely with governments in the combating of illicit trade. This cooperation poses risks for tobacco control, particularly if relationships and norms of cooperation spill over into other areas of FCTC implementation. An examination of the industry's positioning suggests that it sees an opportunity to portray itself as 'legitimate' and 'responsible', a friend of governments, and a way to integrate itself into FCTC processes. This paper makes suggestions for moving forward in this challenging area towards ensuring that the approach taken actually reduces illicit tobacco trade, strengthens tobacco tax policies and does not operate to undermine the FCTC.     

African American leadership groups: smoking with the enemy

BACKGROUND: Among all racial and ethnic groups in the USA, African Americans bear the greatest burden from tobacco related disease. The tobacco industry has been highly influential in the African American community for decades, providing funding and other resources to community leaders and emphasising publicly its support for civil rights causes and groups, while ignoring the negative health effects of its products on those it claims to support. However, the industry's private business reasons for providing such support were unknown. OBJECTIVE: To understand how and for what purposes the tobacco industry sought to establish and maintain relationships with African American leaders. METHODS: Review and analysis of over 700 previously secret internal tobacco industry documents available on the internet. RESULTS: The tobacco industry established relationships with virtually every African American leadership organisation and built longstanding social connections with the community, for three specific business reasons: to increase African American tobacco use, to use African Americans as a frontline force to defend industry policy positions, and to defuse tobacco control efforts. CONCLUSION: As the tobacco industry expands its global reach, public health advocates should anticipate similar industry efforts to exploit the vulnerabilities of marginalised groups. The apparent generosity, inclusion, and friendship proffered by the industry extract a price from groups in the health of their members. Helping groups anticipate such efforts, confront industry co-optation, and understand the hidden costs of accepting tobacco industry largesse should be part of worldwide tobacco control efforts.     

中国烟草"走出去"的实践和几点建议

在经济全球化加速发展的今天,一个产业只有放在全球范围内来审视,才能判断其是否真正具有国际竞争力;一个企业只有在全球范围内有效整合资源,才能成为世界级企业。对于中国烟草来说,“走出去”开展跨国经营,充分利用“两个市场、两种资源”,积极培育新的经济增长点,这是其提高竞争实力,拓展发展空间,谋求长远发展的一项具有重大意义的战略性选择。本文通过回顾中国烟草“走出去”的实践,总结其中的基本经验,对中国烟草制定和宴施“走出去”战略进行了初步思考和探讨。     

基于实证分析的中国烟草产品国际竞争力研究

近年来，中国烟草产业既面临着国外烟草产品进入的冲击以及控烟履约的双重压力，又担当着为国家财政增税的重任，其发展已不能单纯依靠国内需求拉动，更应该积极面向全球需求，开发国际市场。为了精确地测度我国烟草产品的国际竞争力，构建了国际市场占有率（IMS）、贸易竞争力指数（TC）和显性比较优势指数（RCA）三个指标，以计量经济学手段分析了我国烟草产品在全球市场中的主要特征及问题。研究发现，我国烟草及烟草产品的整体竞争力较弱，但烟叶产品在国际市场上有一定的竞争力。      

Tobacco control, global health policy and development: towards policy coherence in global governance

The WHO Framework Convention on Tobacco Control (FCTC) demonstrates the international political will invested in combating the tobacco pandemic and a newfound prominence for tobacco control within the global health agenda. However, major difficulties exist in managing conflicts with foreign and trade policy priorities, and significant obstacles confront efforts to create synergies with development policy and avoid tensions with other health priorities. This paper uses the concept of policy coherence to explore congruence and inconsistencies in objectives, policy, and practice between tobacco control and trade, development and global health priorities. Following the inability of the FCTC negotiations to satisfactorily address the relationship between trade and health, several disputes highlight the challenges posed to tobacco control policies by multilateral and bilateral agreements. While the work of the World Bank has demonstrated the potential contribution of tobacco control to development, the absence of non-communicable diseases from the Millennium Development Goals has limited scope to offer developing countries support for FCTC implementation. Even within international health, tobacco control priorities may be hard to reconcile with other agendas. The paper concludes by discussing the extent to which tobacco control has been pursued via a model of governance very deliberately different from those used in other health issues, in what can be termed 'tobacco exceptionalism'. The analysis developed here suggests that non-communicable disease (NCD) policies, global health, development and tobacco control would have much to gain from re-examining this presumption of difference.     

Achieving the Framework Convention on Tobacco Control's potential by investing in national capacity

May 2003 marked a critical achievement in efforts to stem the global tobacco epidemic, as the member states of the World Health Organization unanimously endorsed the Framework Convention on Tobacco Control (FCTC). However, the adoption of the FCTC signifies only the end of the beginning of effective global action to control tobacco. Over the next several years the utility of the FCTC process and the treaty itself will be tested as individual countries seek to ratify and implement the treaty's obligations. Significant barriers to the treaty's long term success exist in many countries. It is crucial that the international tobacco control community now refocuses its efforts on national capacity building and ensures that individual countries have the knowledge, tools, data, people, and organisations needed to implement the convention and develop sustained tobacco control programmes. This paper provides a model of national tobacco control capacity and offers a prioritised agenda for action.     

How Philip Morris built Marlboro into a global brand for young adults: implications for international tobacco control

Objective: To describe Philip Morris'' global market research and international promotional strategies targeting young adults. Methods: : Analysis of previously secret tobacco industry documents. Results: Philip Morris pursued standardised market research and strategic marketing plans in different regions throughout the world using research on young adults with three principle foci: lifestyle/psychographic research, brand studies, and advertising/communication effectiveness. Philip Morris identified core similarities in the lifestyles and needs of young consumers worldwide, such as independence, hedonism, freedom, and comfort. In the early 1990s Philip Morris adopted standardised global marketing efforts, creating a central advertising production bank and guidelines for brand images and promotions, but allowing regional managers to create regionally appropriate individual advertisements. Conclusions: Values and lifestyles play a central role in the global marketing of tobacco to young adults. Worldwide counter marketing initiatives, coupled with strong, coherent global marketing policies such as the Framework Convention on Tobacco Control, are needed to break associations between young adult values and tobacco brands. As globalisation promotes the homogenisation of values and lifestyles, tobacco control messages that resonate with young adults in one part of the world may appeal to young adults in other countries. Successful tobacco control messages that appeal to young people, such as industry denormalisation, may be expanded globally with appropriate tailoring to appeal to regional values.     

Global assessment of deforestation related to tobacco farming

OBJECTIVES: To assess the global amount of forest and woodland consumed annually for curing tobacco between 1990 and 1995; to estimate tobacco's share in total deforestation; to rank tobacco-growing countries by the degree of impact of tobacco deforestation; and to indicate environmental criticality emerging from tobacco's impact on forest resources. DESIGN: Production of country-specific estimates of forests/woodlands needed and depleted on the basis of growing stock/increment of woody biomass involved and wood consumption of tobacco. Comparison of results with secondary statistics on forest cover, deforestation, and population development. RESULTS: An estimated 200,000 ha of forests/woodlands are removed by tobacco farming each year. Deforestation mainly occurs in the developing world, amounting to 1.7% of global net losses of forest cover or 4.6% of total national deforestation. Environmental criticality exists or is emerging in 35 countries with an estimated serious, high, and medium degree of tobacco-related deforestation, mainly in southern Africa, middle east, south, and east Asia, South America, and the Caribbean. CONCLUSION: The hypothesis that deforestation from tobacco production does not have a significant negative effect has to be challenged. For empirical validation, the globally significant pattern of estimated tobacco-related environmental damage ought to be included in international research agendas on global environmental change, to become an integral and rational part of tobacco control policy.     

Pig's blood in cigarette filters: how a single news release highlighted tobacco industry concealment of cigarette ingredients

The tobacco industry is not obligated to disclose ingredients and additives used in manufactured tobacco production. This paper describes global reaction to a press release highlighting evidence that porcine haemoglobin ("pig's blood") was sometimes used in cigarette manufacturing while never being disclosed to smokers. The case study illustrates the power of press releases to ignite major interest in tobacco control issues.     

Understanding the vector in order to plan effective tobacco control policies: an analysis of contemporary tobacco industry materials

This paper builds on tobacco document research by analysing contemporary materials to explore how the global tobacco market has changed, how transnational tobacco companies (TTCs) are responding and the implications for tobacco control. The methods involved analysis of a variety of materials, including tobacco company annual reports, investor relations materials, financial analyst reports, market research reports and data. Once China, where TTCs have little market share, is excluded, global cigarette volumes are already declining. Nevertheless, industry profits continue to increase. This pattern is explained by the pricing power of TTCs-their ability to increase prices faster than volumes fall, a consequence of market failure. Pricing power is now fundamental to the long term future of TTCs. Consequently, and in light of growing regulations, the business model of the TTCs is changing. Product innovation is now a key marketing technique used to drive consumers to buy more expensive (ie, profitable) premium cigarettes. Contrary to established wisdom, high tobacco excise rates, particularly where increases in excise are gradual, can benefit TTCs by enabling price (profit) increases to be disguised. Large intermittent tax increases likely have a greater public health benefit. TTC investments in smokeless tobacco appear designed to eliminate competition between smokeless tobacco and cigarettes, thereby increasing the pricing power of TTCs while enabling them to harness the rhetoric of harm reduction. Monitoring TTCs can inform effective policy development. The value maximising approach of TTCs suggests that a ban on product innovation and more informed tobacco excise policies are needed.     

Building capacity for tobacco control research and policy

The Fogarty International Center (FIC) initiative, "International Tobacco and Health Research Capacity Building Program" represents an important step in US government funding for global tobacco control. Low- and middle-income countries of the world face a rising threat to public health from the rapidly escalating epidemic of tobacco use. Many are now parties to the Framework Convention on Tobacco Control (FCTC) and capacity development to meet FCTC provisions. One initial grant provided through the FIC was to the Institute for Global Tobacco Control (IGTC) at the Johns Hopkins Bloomberg School of Public Health (JHSPH) to support capacity building and research programmes in China, Brazil, and Mexico. The initiative's capacity building effort focused on: (1) building the evidence base for tobacco control, (2) expanding the infrastructure of each country to deliver tobacco control, and (3) developing the next generation of leaders as well as encouraging networking throughout the country and with neighbouring countries. This paper describes the approach taken and the research foci, as well some of the main outcomes and some identified challenges posed by the effort. Individual research papers are in progress to provide more in-depth reporting of study results.     

变革与挑战:新型烟草制品发展展望

近年来,电子烟、加热不燃烧烟草制品等新型烟草制品正在快速兴起。本文概述了新型烟草制品的主要类型和基本特征,具体介绍了新型烟草制品在国际市场的发展态势,提出了新型烟草制品将是烟草行业的第三次重大变革,可能会对传统烟草行业带来颠覆性影响的观点,回顾了近年来中国烟草围绕技术、装备、产品三个方面开展的新型烟草制品全产业链研发布局情况,最后对新型烟草制品的发展趋势、研发方向、市场前景和行业未来发展战略作了展望。      

Tobacco use in six economically disadvantaged communities in the Dominican Republic.

The Dominican Republic is a tobacco-growing country, and tobacco control efforts there have been virtually nonexistent. This study provides a first systematic surveillance of tobacco use in six economically disadvantaged Dominican Republic communities (two small urban, two peri-urban, two rural; half were tobacco growing). Approximately 175 households were randomly selected in each community (total N = 1,048), and an adult household member reported on household demographics and resources (e.g., electricity), tobacco use and health conditions of household members, and household policies on tobacco use. Poverty and unemployment were high in all communities, and significant gaps in access to basic resources such as electricity, running water, telephones/cell phones, and secondary education were present. Exposure to tobacco smoke was high, with 38.4% of households reporting at least one tobacco user, and 75.5% allowing smoking in the home. Overall, 22.5% reported using tobacco, with commercial cigarettes (58.0%) or self-rolled cigarettes (20.1%) the most commonly used types. Considerable variability in prevalence and type of use was found across communities. Overall, tobacco use was higher in males, illiterate groups, those aged 45 or older, rural dwellers, and tobacco-growing communities. Based on reported health conditions, tobacco attributable risks, and World Health Organization mortality data, it is estimated that at least 2,254 lives could potentially be saved each year in the Dominican Republic with tobacco cessation. Although it is expected that the reported prevalence of tobacco use and health conditions represent underestimates, these figures provide a starting point for understanding tobacco use and its prevalence in the Dominican Republic.     

The development of tobacco use in adolescence among "snus starters" and "cigarette starters": an analysis of the Swedish "BROMS" cohort

Whether the use of smokeless tobacco can facilitate the transition to cigarette smoking and/or to prolonged tobacco use in adolescence is unclear. We analyzed data from a cohort of 2,938 Swedish adolescents, with six follow-up assessments of tobacco use between the ages of 11 and 18 years. The majority of tobacco users (70%) started by smoking cigarettes, 11% took up snus before smoking, and 19% used both tobacco types close in time. Ever users of tobacco at baseline had a higher risk of being current smokers and/or smokeless tobacco users at the end of follow-up compared with never users, with the highest excess relative risk for "mixed users." Adolescents who initiated tobacco use with cigarettes had a non-significantly increased probability to end up as current smokers compared with snus starters (adjusted OR=1.42; 95% CI 0.98-2.10) The OR of smoking for "mixed starters" was 2.54 (95% CI 1.68-3.91). The risk of becoming current user of any tobacco was also significantly enhanced for "mixed starters." Marked sex differences were observed in these associations, as initiation with cigarettes rather than with snus predicted current smoking or tobacco use only among females. Progression of tobacco use in adolescence is not predicted by onset with snus or cigarettes, but rather by initiation with both tobacco types close in time and/or at young age. The proportion of adolescent smoking prevalence attributable to a potential induction effect of snus is likely small.