International trade agreements: a threat to tobacco control policy

International covenants establish a role for governments in ensuring the conditions for human health and wellbeing, which has been recognised as a central human right. International trade agreements, conversely, prioritize the rights of corporations over health and human rights. International trade agreements are threatening existing tobacco control policies and restrict the possibility of implementing new controls. This situation is unrecognised by many tobacco control advocates in signatory nations, especially those in developing countries. Recent agreements on eliminating various trade restrictions, including those on tobacco, have expanded far beyond simply international movement of goods to include internal tobacco distribution regulations and intellectual property rules regulating advertising and labelling. Our analysis shows that to the extent trade agreements protect the tobacco industry, in itself a deadly enterprise, they erode human rights principles and contribute to ill health. The tobacco industry has used trade policy to undermine effective barriers to tobacco importation. Trade negotiations provide an unwarranted opportunity for the tobacco industry to assert its interests without public scrutiny. Trade agreements provide the industry with additional tools to obstruct control policies in both developed and developing countries and at every level. The health community should become involved in reversing these trends, and help promote additional measures to protect public health.     

Framing tobacco control efforts within an ethical context

Public health efforts to promote tobacco control are not performed within a vacuum. They are subject to interpretation and misinterpretation by consumers and policymakers based largely upon the initial framing of the issues. This paper notes how the tobacco industry has established a particular frame that it is the protector of individual rights and that the public health community is trying to eliminate those rights. This paper then shows how the public health community uses metaphors that may unintentionally support this framing and suggests that by reframing public health efforts in accordance with core ethical principles, the public health community can create more positive messages. A public health ethical framework is proposed to examine how the application of the principles can influence the tobacco control movement. Through the increased use of ethics in tobacco control, the public health community may be better positioned to claim the high road as the protector of the public's interests.     

Philip Morris's Project Sunrise: weakening tobacco control by working with it

Objective

To analyse the implications of Philip Morris USA''s (PM''s) overtures toward tobacco control and other public health organisations, 1995–2006.

Data sources

Internal PM documents made available through multi‐state US attorneys general lawsuits and other cases, and newspaper sources.

Methods

Documents were retrieved from several industry documents websites and analysed using a case study approach.

Results

PM''s Project Sunrise, initiated in 1995 and proposed to continue through 2006, was a long‐term plan to address tobacco industry delegitimisation and ensure the social acceptability of smoking and of the company itself. Project Sunrise laid out an explicit divide‐and‐conquer strategy against the tobacco control movement, proposing the establishment of relationships with PM‐identified “moderate” tobacco control individuals and organisations and the marginalisation of others. PM planned to use “carefully orchestrated efforts” to exploit existing differences of opinion within tobacco control, weakening its opponents by working with them. PM also planned to thwart tobacco industry delegitimisation by repositioning itself as “responsible”. We present evidence that these plans were implemented.

Conclusion

Sunrise exposes differences within the tobacco control movement that should be further discussed. The goal should not be consensus, but a better understanding of tensions within the movement. As the successes of the last 25 years embolden advocates to think beyond passage of the next clean indoor air policy or funding of the next cessation programme, movement philosophical differences may become more important. If tobacco control advocates are not ready to address them, Project Sunrise suggests that Philip Morris is ready to exploit them.     

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.     

Public health foundations and the tobacco industry: lessons from Minnesota

Objective: To investigate whether private foundations can be created in a way that will insulate them from attacks by the tobacco industry, using the Minnesota Partnership for Action Against Tobacco (MPAAT) as a case study.

Design: Information was collected from internal tobacco industry documents, court documents, newspapers, and interviews with health advocates and elected officials.

Results: The creation of MPAAT as an independent foundation did not insulate it from attacks by tobacco industry allies. During 2001–2002, MPAAT was repeatedly attacked by Attorney General Mike Hatch and major media, using standard tobacco industry rhetoric. This strategy of attack and demands for information were reminiscent of previous attacks on Minnesota's Plan for Nonsmoking and Health and the American Stop Smoking Intervention Study (ASSIST). MPAAT was ultimately forced to restructure its programme to abandon effective community norm change interventions around smoke-free policies and replace them with less effective individual cessation interventions. Neither MPAAT nor other health advocates mounted an effective public response to these attacks, instead relying on the insider strategy of responding in court.

Conclusion: It is not possible to avoid attacks by the tobacco industry or its political allies. Like programmes administered by government agencies, tobacco control foundations must be prepared for these attacks, including a proactive plan to educate the public about the principles of community based tobacco control. Public health advocates also need to be willing to take prompt action to defend these programmes and hold public officials who attack tobacco control programmes accountable for their actions.

     

Individual rights advocacy in tobacco control policies: an assessment and recommendation

Efforts to control environmental tobacco smoke (ETS) could be assisted if the tobacco control movement gave greater emphasis to the issue of individual rights. Benefits that may accrue from the promotion of a clear individual rights perspective in tobacco control include adding coherence to the tobacco control advocacy agenda and winning support from those who may have been concerned about loss of personal freedom, excessive governmental power, use of social coercion, or the rights of smokers. Risks also attend to such a policy. It might inadvertently assist the tobacco industry, stir resistance to ETS limitation efforts, or confuse tobacco control supporters. On balance, though, liabilities are outweighed by the ethical and operational merits in tobacco control of a heightened pro-individual rights stance.     

Evolution of a comprehensive tobacco control programme: building system capacity and strategic partnerships--lessons from Massachusetts

BACKGROUND: Since the passage of a voter approved state referendum in 1992 to establish a 25 cent increase on the excise tax on cigarettes and smokeless tobacco, Massachusetts has received an average of $40 million annually for its tobacco control programme. This funding allowed Massachusetts to expand and develop its tobacco control programme to become one of the most comprehensive in the world. OBJECTIVES: The development of the Massachusetts Tobacco Control Program is outlined, focusing on three stages of development: formation, strategic partnership building, and shared leadership. METHODS: The development of management structures, programmatic infrastructure, communication and partnership networks, and advisory structures are tracked throughout the three phases. RESULTS: The use of pre-existing public health resources, implementation of a strong training component, a geographical management structure, the creation of public and private partnerships, and the development of a shared leadership model contributed to building consensus and provided the foundation for coordinated approaches to tobacco control. CONCLUSION: Other states and countries can use lessons learned from Massachusetts about the organisational development of a comprehensive tobacco control programme as they embark upon similar efforts.     

Thinking the "unthinkable": why Philip Morris considered quitting

Objective: To investigate the genesis and development of tobacco company Philip Morris''s recent image enhancement strategies and analyse their significance. Data sources: Internal Philip Morris documents, made available by the terms of the Master Settlement Agreement between the tobacco companies and the attorneys general of 46 states, and secondary newspaper sources. Study selection: Searches of the Philip Morris documents website (www.pmdocs.com) beginning with terms such as "image management" and "identity" and expanding as relevant new terms (consultant names, project names, and dates), were identified, using a "snowball" sampling strategy. Findings and conclusions: In the early 1990s, Philip Morris, faced with increasing pressures generated both externally, from the non-smokers'' rights and public health communities, and internally, from the conflicts among its varied operating companies, seriously considered leaving the tobacco business. Discussions of this option, which occurred at the highest levels of management, focused on the changing social climate regarding tobacco and smoking that the tobacco control movement had effected. However, this option was rejected in favour of the image enhancement strategy that culminated with the recent "Altria" name change. This analysis suggests that advocacy efforts have the potential to significantly denormalise tobacco as a corporate enterprise.     

Human rights-based approach to tobacco control

The Framework Convention for Tobacco Control (FCTC) is currently the most potent tool for implementation of tobacco control laws across the globe. The FCTC is derivative from previously constructed international human rights conventions. These previous conventions have enforcement mechanisms, unlike the FCTC. However, the FCTC relies on state parties to report periodically on its implementation rather than on a continuous monitoring system. The Human Rights and Tobacco Control Network proposes that abiding by the principles of human rights delineated by international treaties, citizens across the globe can demand effective action for tobacco control. This paper explains the link between fundamental human rights and the right to tobacco control. Mechanisms are described to link the FCTC and its principles with human rights-based monitoring reports, which are provided to oversight committees for the other human rights conventions. The initial work of the Human Rights and Tobacco Control Network is summarised and considers the future directions for the human rights-based approach to tobacco control.     

The human rights responsibilities of multinational tobacco companies

This article explores various strategies which could be used to hold the tobacco industry accountable for human rights violations precipitated by its conduct. First, a brief overview of the international human rights regime and the tobacco related jurisprudence issued by human rights treaty bodies is provided. The article then explains how tobacco control advocates could promote more systematic consideration of governments' tobacco related human rights violations by reconceptualising the Framework Convention on Tobacco Control in the language of rights. The feasibility of using the existing human rights framework to target the tobacco industry directly is analysed with the conclusion that this approach has serious limitations. Emerging human rights norms, which have greater potential to affect the industry's conduct, are presented. Finally, given the questionable authoritativeness of these norms, alternative ways that they could be employed to hold tobacco companies accountable for the rights related consequences of their activities are proposed.     

The perimetric boycott: a tool for tobacco control advocacy

Objectives: To propose criteria to help advocates: (1) determine when tobacco related boycotts may be useful; (2) select appropriate targets; and (3) predict and measure boycott success. Methods: Analysis of tobacco focused boycotts retrieved from internal tobacco industry documents websites and other scholarship on boycotts. Results: Tobacco related boycotts may be characterised by boycott target and reason undertaken. Most boycotts targeted the industry itself and were called for political or economic reasons unrelated to tobacco disease, often resulting in settlements that gave the industry marketing and public relations advantages. Even a lengthy health focused boycott of tobacco industry food subsidiaries accomplished little, making demands the industry was unlikely to meet. In contrast, a perimetric boycott (targeting institutions at the perimeter of the core target) of an organisation that was taking tobacco money mobilised its constituency and convinced the organisation to end the practice. Conclusions: Direct boycotts of the industry have rarely advanced tobacco control. Perimetric boycotts of industry allies offer advocates a promising tool for further marginalising the industry. Successful boycotts include a focus on the public health consequences of tobacco use; an accessible point of pressure; a mutual interest between the target and the boycotters; realistic goals; and clear and measurable demands.     

Understanding Philip Morris's pursuit of US government regulation of tobacco

Objective: To investigate Philip Morris's support of US Food and Drug Administration (FDA) regulation of tobacco products and analyse its relationship to the company's image enhancement strategies.

Data sources: Internal Philip Morris documents released as part of the Master Settlement Agreement.

Methods: Searches of the Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu) beginning with such terms as "FDA" and "regulatory strategy" and expanding to include relevant new terms.

Results: Philip Morris's support for government regulation of tobacco is part of a broader effort to address its negative public image, which has a damaging impact on the company's stock price, political influence, and employee morale. Through regulation, the company seeks to enhance its legitimacy, redefine itself as socially responsible, and alter the litigation environment. Whereas health advocates frame tobacco use as a public health policy issue, Philip Morris's regulatory efforts focus on framing tobacco use as an individual choice by informed adults to use a risky product. This framing allows Philip Morris to portray itself as a reasonable and responsible manufacturer and marketer of risky products.

Conclusions: Philip Morris's ability to improve its image through support of FDA regulation may undermine tobacco control efforts aimed at delegitimising the tobacco industry. It may also create the impression that Philip Morris's products are being made safer and ultimately protect the company from litigation. While strong regulation of tobacco products and promotion remain critical public health goals, previous experiences with tobacco regulation show that caution may be warranted.

     

British Columbia capital regional district 100% smokefree bylaw: a successful public health campaign despite industry opposition

Objective: To describe how the British Columbia Capital Regional District successfully passed, implemented, and enforced a 100% smokefree bylaw in all public places, including restaurants and bars, despite an aggressive campaign by the tobacco industry (acting through the hospitality industry) to stop it. Methods: Information was obtained from news reports, internal tobacco industry documents, reports, public documents, and interviews with key players. Tobacco industry documents were accessed between February and April 2002. This project was approved by the University of California San Francisco committee on human research. Results: As in the USA and elsewhere in the world, the tobacco industry in British Columbia, Canada, recruited and created hospitality associations to fight against the district smokefree bylaw. They used the classic industry rhetoric of individual rights and freedoms, economic devastation, and ventilation as a solution. Public health authorities were able to counter industry strategies with a strong education campaign, well written bylaws, and persistent enforcement. Conclusion: It is possible to overcome serious opposition orchestrated by the tobacco industry and develop and implement a 100% smokefree bylaw in Canada. Doing so requires attention to detail in drafting the bylaw, as well as a public education campaign on the health dangers of secondhand smoke and active enforcement to overcome organised resistance to the bylaw. Jurisdictions considering smokefree bylaws should anticipate this opposition when developing and implementing their bylaws.     

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.     

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.     

Allying tobacco control with human rights: invited commentary

The recognition that tobacco control and human rights concerns overlap is quite recent. This commentary reflects upon tobacco control's growth through allying with other domains, and details a particular effort to build alliances between tobacco control and human rights practitioners.     

Industry Front Groups: A Tobacco Case Study

We consider how industries use front groups to combat public health measures by relating the history of “Get Government Off Our Back”, a coalition created by the tobacco industry to fight government regulation. Using tobacco industry documents, contemporaneous media reports, journal articles, and press releases, we review the establishment by RJ Reynolds of an industry front group, Get Government Off Our Back (GGOOB) in 1994. The group’s goal was to advocate against U.S. federal regulation of tobacco. By keeping its involvement secret, RJ Reynolds was able to draw public and legislative support toward limiting government regulation of tobacco without having to address the tobacco industry’s reputation for misrepresenting evidence. Unfortunately, the tobacco industry”s use of front groups is not unique; other industries use front groups to fight measures designed to protect public health. Research on the background and funding of advocacy organizations could help identify industry front groups and make them less useful to their creators.     

"Creative Solutions": selling cigarettes in a smoke-free world

Objective: To analyse the development and execution of the "Creative Solutions" Benson & Hedges advertising campaign to understand its social, political, and commercial implications. Methods: Searches of the Philip Morris documents and Legacy Tobacco Documents websites for relevant materials; Lexis/Nexis searches of major news and business publications; and denotative and connotative analyses of the advertising imagery. Results: Philip Morris developed the Creative Solutions campaign in an effort to directly confront the successes of the tobacco control movement in establishing new laws and norms that promoted clean indoor air. The campaign''s imagery attempted to help smokers and potential smokers overcome the physical and social downsides of smoking cigarettes by managing risk and resolving internal conflict. The slogans suggested a variety of ways for smokers to respond to restrictions on their habit. The campaign also featured information about the Accommodation Program, Philip Morris''s attempt to organise opposition to clean indoor air laws. Conclusion: The campaign was a commercial failure, with little impact on sales of the brand. Philip Morris got some exposure for the Accommodation Program and its anti-regulatory position. The lack of commercial response to the ads suggests that they were unable to successfully resolve the contradictions that smokers were increasingly experiencing and confirms the power of changing social norms to counter tobacco industry tactics.     

Tobacco lobby political influence on US state legislatures in the 1990s

BACKGROUND: Throughout the 1990s the tobacco lobby was a potent political force in US state legislatures advancing its pro-tobacco agenda. OBJECTIVE: To describe the market and political motivations of the tobacco lobby and the strategies they use to achieve these goals in US state legislatures. DESIGN: This study is a content analysis and summary overview of recently released historical tobacco industry documents; tobacco related government documents; and recent state tobacco control policy reports. RESULTS: In the 1990s, the tobacco lobby engaged in a comprehensive and aggressive political effort in state legislatures to sell tobacco with the least hindrance using lobbying, the media, public relations, front groups, industry allies, and contributions to legislators. These efforts included campaigns to neutralise clean indoor air legislation, minimise tax increases, and preserve the industry's freedom to advertise and sell tobacco. The tobacco lobby succeeded in increasing the number of states that enacted state pre-emption of stricter local tobacco control laws and prevented the passage of many state tobacco control policies. Public health advocates were able to prevent pre-emption and other pro-tobacco policies from being enacted in several states. CONCLUSIONS: The tobacco lobby is a powerful presence in state legislatures. Because of the poor public image of the tobacco lobby, it seeks to wield this power quietly and behind the scenes. State and local health advocates, who often have high public credibility, can use this fact against the tobacco lobby by focusing public attention on the tobacco lobby's political influence and policy goals and expose links between the tobacco lobby and its legislative supporters.     

Industry Front Groups: A Tobacco Case Study

We consider how industries use front groups to combat public health measures by relating the history of “Get Government Off Our Back”, a coalition created by the tobacco industry to fight government regulation. Using tobacco industry documents, contemporaneous media reports, journal articles, and press releases, we review the establishment by RJ Reynolds of an industry front group, Get Government Off Our Back (GGOOB) in 1994. The group’s goal was to advocate against U.S. federal regulation of tobacco. By keeping its involvement secret, RJ Reynolds was able to draw public and legislative support toward limiting government regulation of tobacco without having to address the tobacco industry’s reputation for misrepresenting evidence. Unfortunately, the tobacco industry”s use of front groups is not unique; other industries use front groups to fight measures designed to protect public health. Research on the background and funding of advocacy organizations could help identify industry front groups and make them less useful to their creators. Received: July 2, 2007; Accepted: July 4, 2007