25950 May 2003 iobiaccokwCiniRiAOy STRATEGIES 0SUCCESSES & SETBACKS Edited by Joy de Beyer and Linda Wave'rley Brigden Tobacco Control Policy Strategies, Successes, and Setbacks Tobacco Control Policy Strategies, Successes, and Setbacks Edited by Joy de Beyer and Linda Waverley Brigden 3 ritc PN rmct A copublication of the World Bank and Research for International Tobacco Control (RITC) Copyright © 2003 The Intemational Banlk for Reconstructicn and Development / The World Bank 1818 H Street NW Washington, DC 20433, USA and The International Development Research Centre on behalf of the Research for International Tobacco Control Secr-etariat P.O. Box 8500, Ottawa, Ontario, Canada, KIC 3H9 All rights reserved. 1 2 3 4 06 05 04 03 The findings, interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflect the views of the Board of Executive Directors of the World Bank or the governments they represent. 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All other queries on rights and licenses, including subsidiaiy rights, should be ad- dressed to the Office of the Publisher, WorId Bank, 18 t8 H Street NW, Washington, DC 20433, USA, fax 202-522-2422, e-mail pubrightsCworld ank.org. Cover Design by Choon Shim, Creatrix Design Group, Otta wa, Canada. ISBN 0-8213-5402-7 Library of Congress Cataloging-in-Publication Data has been applied for. Table of Contents Foreword ............ ix Preface ............ xi Acknowledgments ........................................... xiii Contributors ............ xiv Abbreviations, Acronyms, and Data Note ........................ xvi 1. Overview ............................................... 1 Joy de Beyer and Linda Waverley Brigden Why These Six Countries? ................................... 2 What Factors Made the Difference? ........... ................ 7 The Big Picture ....................................... 9 References ....................................... 11 2. Building Momentum for Tobacco Control: The Case of Bangladesh ................................... 13 Debra Efroymson and Saifuddin Ahmed Tobacco in the Lives of the Bangladeshi People ...... .......... 14 A Chronicle of Tobacco Control in Bangladesh ...... ........... 20 The Politics of Policymaking ................................ 28 Lessons Learned ......................... 31 Conclusion ......................... 36 References ......................... 36 v Vi CONTENTS 3. Government Leadership in Tobacco Control: Brazil's Experience ....................................... 38 Luisa M. da Costa e Silva Goldfirb The Scope of the Tobacco Problem in Brazi .... .............. 38 The Beginnings of Tobacco Control in Brazil ................... 40 Gaining Momentum: The National Tobacco Control Program .... 42 Swift Action and Strong Support: A Legislative Victory .......... 52 More Tobacco Control Legislaticn ........................... 56 Education: The Basis of the NTCP ....... .................... 57 Legislative Action: Education's Partner ...... ................. 60 The Other Side of the Picture: What Stimulates Consumption? ... 61 Lessons Learned ................... .................... 66 References ................... 67 4. Legislation and Applied Economics in the Pursuit of Public Health: Canada ................................... 71 David Sweanor and Ken Kyle A Generation Gap: Before Tobacco Control ...... .............. 72 The 1980s: A Decade of Change .......... ................... 74 Working for Policy Change: An Overview ...... .............. 76 Lessons Learned .......................................... 92 Appendix: Key Dates in Tobacco Control in Canada ..... ....... 95 References ........................................... 96 5. Democracy and Health: Tobacco Conttrol in Polind ..... ....... 97 Witold Zatoniski Tobacco Consumption in Poland: HistoricaL Background ........ 97 The Impact of Democracy and a Free Market ................. 103 New Legislation for Tobacco Control ....... ................. 107 The Role of Cigarette Pricing ............................... 111 Advertising Back on the Agenda ........................... 112 Democracy Is Healthier ............... .............. 112 Lessons Learned ................... .................. 116 References ................ .......... .................. 119 6. Political Change in South Africa: New Tobacco Control and Public Health Policies ................... 121 Mia Malan and Rosemiiary Leaver The History: Early Days, Early Stbuggles ..................... 121 Building Support .............................. 128 CONTENTS vii The Road to Legislation ................................... 131 New Government, New Regulations ........................ 136 Implications for the Provinces: New Hope for Cape Town ...... 138 National Developments ................................... 140 1999 Legislation ......................................... 146 Conclusion ............................................. 149 References .............................................. 151 7. Tailoring Tobacco Control Efforts to the Country: The Example of Thailand ................................. 154 Prakit Vateesatokit The Story Begins: Small Steps Forward ...................... 154 Building Support: The TASCP's Formative Years ..... ......... 156 Challenges from Beyond: Tobacco Trade Wars ................ 157 Point-Counterpoint: Trade versus Health .................... 159 The Sometimes Fine Art of Raising Tobacco Taxes ..... ........ 162 Toward a Dedicated Tax for Health Promotion ................ 164 Continuing Opposition from the Tobacco Companies .......... 166 The Role of the Nongovernmental Sector ...... .............. 168 Spreading the Message: Thai Women Do Not Smoke ........... 170 Successes and Challenges ................................. 171 Lessons Learned ............................... I....... .. 173 Appendix: Chronological Summary of Tobacco Control Efforts in Thailand . .......................................... 175 References .............................................. 176 Index ..................................................... 179 Figures 1.1 Deaths Attributable to Selected Leading Risk Factors, Worldwide, 2000 ...................................... 2 1.2 Disease Burden Attributable to Selected Leading Risk Factors, Worldwide, 2000 ...................................... 3 3.1 Trends in Cigarette Consumption and Real Prices, Brazil, 1983-94 ............. 46 3.2 Prices of Imported and Local-Brand Cigarettes, Selected Economies, March 2001 ............................... 63 3.3 Trends in Per Capita Cigarette Consumption by People Age 15 and Older, Brazil, 1980-99 ....................... 65 4.1 Examples of Canadian Pictorial Warning Labels for Cigarette Packages .... 85 Viii CONTENTS 4.2 Cigarette Consumption and Real Cigare tte Prices, Canada, 1949-98 ..................................... 9]L 4.3 Smoking Prevalence among Teenagers Age 15-19, Regular Smokers, Canada, 1977-94 ...................... 92 5.1 Probability of Dying of Various Causes for Men Age 15-59, by Region, 1990 ...................................... 98 5.2 Mortality Trends for Lung Cancer, All Age Groups, Men and Women, Poland, the United Kingdom, and the United States, 1959-99 ..... . ................. 100 5.3 Mortality Trends for Lung Cancer, M/.en Age 43-64, Poland, the United Kingdom, and the United States, 1959-99 ...... 101 5.4 Nominal and Real Trends in Tobacco Excise Taxes and Average Monthly Salaries, Poland, 1993-2002 ......... 111 5.5 Smoking Prevalence by Age Group, Men and Women, Poland, 1975, 1985, and 1999 .................. ... 114 6.1 De KLerk Prepares to Take Leave oF Power and the Tobacco Control Debate: A Cartocnist's Perspective .134 6.2 Real and Nominal Cigarette Prices and Taxes, South Africa, 1961-2000 .142 6.3 Zuma versus Rupert: A Cartoonist's View. .144 6.4 Potential and Actual Cigarette Tax Revenues (Excise and Sales Taxes Combined), Sout-h Africa, .971-2000 .......... 145 6.5 Real Cigarette Prices and Smoking Preva Lence by Income Group, South Africa, 1993-2000 .. ....... ............. 150 Tables 1.1 Indicators of Development, Tobacco Use, Healih Impact, and Cigarette Prices in Six Countries. 4 2.1 Smoking Rates by Age and Sex, Bangladesh, 1997 .14 2.2 Annual Tobacco Trade and Agricultural Statistics, Bangladesh, Selected Years, 1970-98 .15 3.1 Maximum Levels for Three lI-armful Cigarette Smoke Ingredients, Brazil and the European lnion .57 Foreword Every 10 seconds, someone dies of a tobacco-related disease. This fact is especially painful because the tobacco epidemic is one of the leading pre- ventable causes of death and disability among adults in the world today. In addition, passive smoking has a major effect upon health, especially of children. Once largely a problem in high-income countries, the epidemic caused by tobacco use has become an enormous and growing problem in many low- and middle-income countries. Already, half of all global deaths from tobacco occur in these countries; by 2025, the proportion will have risen to 70 percent, and the number of tobacco-attributable deaths will exceed 10 million each year. This trend is exacerbated by the efforts of cigarette companies to expand sales in developing countries, where many people are still poorly informed about the harm to health that tobacco causes and many governments have not yet adopted or implemented strong policies to discourage tobacco use. In one sense, the remedy is simple-not to use tobacco products. But deterring young people from experimenting with cigarettes and encour- aging smokers to quit adds up to a big challenge. Most people underesti- mate the health risks of tobacco use and hugely underestimate how addictive nicotine is and how hard it is to quit. Social norms and pressures to smoke are difficult to counter, especially in the face of aggressive, alluring advertising that associates smoking with success, strength, inde- pendence, glamour, and sex. But it can be done, in both developed and developing nations. Advertising and promotion of cigarettes has been and can be stopped. Prices can be raised, and smoking banned in public places. Quit attempts can become more common and more likely to suc- ceed with professional and peer support and help. Tobacco control mea- sures are also extremely cost-effective. There are many countries where committed individuals, civil society groups, and governments have worked together to define, advocate, leg- islate, and implement effective tobacco control policies. This book tells the ix x FOREWORD stories of six of these countries, showing how deternined and sustained efforts resulted in health-promoting tobacco control policies. These efforts are paying off: the percentage of smokers has declined in many countries, sowing the seeds for long-term gains in health outcomes. There is still much to be done in these six countries and elsewhere around the world. I anticipate that the world's first international health treaty, the Framework Convention on Tobacco Control, will boost national efforts to adopt and implement policies to reduce tobacco use and prevent the unnecessary deaths and disease tobacco causes. Dr Judith Mackay Director, Asian Consultancy on Tobacco Control Preface This book was commissioned and published in the hope that descriptions of strategies, successes, and setbacks in promoting stronger tobacco control policies around the world would be of wide interest and might be useful to people grappling with similar issues. As participants in academic, ad- vocacy, and policy meetings on tobacco control, we have been struck by the impact of real-life stories and examples. We have been educated and edified by many excellent presentations and discussions of the principles, practice, and impact of tobacco control policy-but what we remember most clearly, long after, are the stories. We have seen rooms come alive with interest and crackle with energy when people who had been at the center of efforts to develop tobacco control policy related their experiences. So, we decided to record and share some of those stories. The case studies in this book are addressed to a wide set of readers who share an interest in health issues and policy-people in nongovernmental organizations, community activists, scientists, decisionmakers, health officials, and members of the public. Each story is set in the unique his- torical, cultural, and political environment of a particular country, but there are common threads and shared lessons that can be applied and adapted in many other countries and circumstances. Most of the stories are told by advocates, many of them health profes- sionals, who were (and often still are) centrally involved in promoting and developing policies and programs to reduce the harm to health caused by tobacco use. Tobacco control is a contentious issue because strong policies to reduce tobacco use are always opposed by groups with an economic interest in the tobacco industry. This book is not a dispas- sionate or theoretical analysis of how policies are made but a set of some- times rather personal accounts and perceptions of how tobacco control policy evolved in six countries and of the strategies, actions, and people that played a role in promoting policies to curb tobacco use. They are sto- ries of commitment, determination, passion, and perseverance-often in the face of formidable opposition. They show how a few committed indi- viduals can bring about change even when confronted with powerful, xi Xii PREFACE well-funded opponents. They also docunent the practical lessons that have been learned in the course of working foil policy change. This book complements (and is quite different from) the numerous scholarly and analytical works on tobacco use and control. The prevalence and health impact of smoking and other for[ns of tobacco use, within individual countries and globally, have been well do umented elsewhere, as has the insidious spread of the epiderri. to develcping countries.1 This book does not present data on the negative health impact of tobacco use or estimate the resulting deaths and illnesses, nor is it a political mapping or analysis of the policymaking process. ]t is, quLite Ii.erally, a collection of stories about tobacco control policyrnaking that illustrate the roles that can be played by evidence, advocacy, political and social change, partner- ships, media, public relations and public pressure, economic interests, and adversity and opportunity. The six countries were selected to provide global geographic represen- tation but also because all have made great progress (although to varying degrees) in adopting and implementing sound tobacco control policies. Many other countries also have strategies to share, successes to celebrate, and setbacks to lament-too many to be contained in one volume. In each of the countries represented in this book, there is still much to be done to protect young people and adults from the unr,ecessary and preventable disease and premature death caused by tobacco use. The narratives gath- ered here are stories of optimism and of change. It is hoped that they will inspire successful efforts toward developing strong and effective tobacco control policies in other countries. Joy de Beyer Liida Waverley Brigden May 2003 1. See, for example, the references cited in chapter 1. Acknowledgments The following organizations provided financial support for this book: * The Human Development Network of the World Bank * Research for International Tobacco Control (RITC) * The Office on Smoking and Health of the U.S. Centers for Disease Con- trol and Prevention * The Tobacco Free Initiative of the World Health Organization. Special thanks are due to Mon-tasser Kamal who, during his time at RITC, played a key role in commissioning and reviewing the contributions. We are grateful to the authors who related their countries' stories and to the people who patiently reviewed the drafts and provided additional details and comments or who shared their own papers and archives. In particular, we thank Iraj Abedian, Ed Elmendorf, Vera da Costa e Silva, Yussuf Saloojee, Richard Skolnik, Krisela Steyn, Corne van Walbeek, Nick Wilkins, and Derek Yach. We also thank copyeditors Ruth Wilson and Yvonne van Ruskenveld of West Coast Editorial Associates and Nancy Levine for the professional polish they brought to the volume. xiii Contribl-Ltors Saifuddin Ahmed is the president of Work for a Better Bangladesh and coordinator of the Bangladesh Anti-Tobacco Alliance. Mr. Ahmed also plays an active role in the SAARC (South Asian Association for Regional Cooperation) Tobacco Control Network and in the Framework Conven- tion Alliance for a strong Framework Convention on Tobacco Control. Linda Waverley Brigden is the executive director of Research for Interna- tional Tobacco Control (RITC), an international secretariat housed at Canada's International Development Research Centr,e (IDRC). Debra Efroymson is the regional directo.r (Asia) of PATH Canada (Pro- gramme for Appropriate Technology in Health, Canada). Ms. Efroymson currently manages tobacco contro L programs in BanS ladesh, India, Nepal, and Vietnam. Luisa M. da Costa e Silva Goldfarb is the national coordinator of school programs for Brazil's National Tobacco Control Program (NTCP) and has been working in tobacco control since the inception of the NTCP in 1991. From 1999 to 2001, she was a Brazilian delegate on working groups and negotiating bodies for the Framework Convention on Tobacco Control. She has served as executive secretary of the Brazilian inter-ministerial Na- tional Commnission on Tobacco Use. Joy de Beyer is an economist who works for the World Bank, coordinat- ing the organization's support for tobacco control around the world. Ken Kyle heads the Public Issues Office of the Canadian Cancer Society in Ottawa. As a government relations professional, he has played a piv- otal role in tobacco control policy issues for more than 15 years. xiv CONTRIBUTORS xv Rosemary Leaver researched and summarized 4,000 tobacco-related arti- cles that appeared in South African newspapers and magazines over the period 1988-98. The research was conducted as part of the second phase of the Economics of Tobacco Control Project in South Africa at University of Cape Town Applied Fiscal Research Center (AFREC). Mia Malan is a senior media correspondent in South Africa, covering key health issues. She has received numerous awards for excellence in journalism. David Sweanor is a lawyer who has worked full time on a wide range of Canadian and global tobacco control issues since 1983. He is the legal coun- sel to the Non-Smokers' Rights Association and the Smoking and Health Action Foundation, affiliated Canadian nongovernmental organizations. Prakit Vateesatokit is a professor and dean, Faculty of Medicine, Ra- mathibodi Hospital, Mahidol University, Bangkok. He is also executive secretary of the Action on Smoking and Health (ASH) Foundation; second vice-chairperson of the Thai Health Promotion Foundation; and a mem- ber of the National Committee for the Control of Tobacco Use, Ministry of Public Health. Witold Zatoxiski is the director of the Division of Epidemiology and Can- cer Prevention at the Maria Sklodowska-Curie Memorial Cancer Centre in Warsaw. His department is the WHO Collaborating Centre on the Action Plan for a Tobacco-Free Europe. He is a member of the Committee of Epi- demiology and Public Health at the Polish Academy of Science and has served as a regional coordinator for tobacco control with the International Union against Cancer (UICC). Abbreviations, Acronyms, and Data EN:ote ABIFUMO National Tobacco Manufact-urers of Brazil (Associacao Brasileira da Industr ia de Fumo) ADHUNIK Amra Dhump.m Nibaron Kori ("WNe prevent tobacco") (Bangladesh) AFTA ASEAN Free Trade Agreement AFUBRA Brazilian Tobacco Growoiers Association ANC African National Cong]ress (South Africa) ANVISA National Sanitary Vigilance Agency (Brazil) APACT Asia-Pacific Association for the Control of Tobacco ASEAN Association of Southeast Asian Nations ASH Action on Smoking and Health (successor to TASCP) (Thailand) BADSA Body Against Destructive Social Activities (Bangladesh) BAT British American Tobacco BATA Bangladesh Anti-Tobacco Alliance BTC Bangladesh Tobacco Company CAB Consumers' Association of Bang!adesh CAT Coalition Against Tobacco (Bangladesh) CCCTB Coordinating Committee for Tobacco Control in Brazil CCS Canadian Cancer Society CCSH Canadian Council on Smoking and Health CCSNA Centre for Clinical Studies on Nicotine Addiction (Brazil) CDC Centers for Disease Control and Prevention (United States'l CLACCTA Latin America,n Coordinating Committee for Tobacco Control CONTAPP National Coordination of Tobacco Control and Primary Cancer Prevention (Brazil) ETCSA Economics of Tobacco Control Project in South Africa EU European Union xvi ABBREVIATIONS, ACRONYMS, AND DATA NOTE xvii FCTC Framework Convention on Tobacco Control FDF Folk Doctors Foundation (Thailand) FEDHASA Federation of Hotel, Liquor and Catering Associations of South Africa FUNASA National Health Foundation (Fundacao Nacional de Saude) GATT General Agreement on Tariffs and Trade HSRI Health Systems Research Institute (Thailand) IACIB Institute of Allergy and Clinical Immunology, Bangladesh IDRC International Development Research Centre (Canada) IMF International Monetary Fund INB Intergovernmental Negotiating Body (for the Framework Convention on Tobacco Control) INCA National Cancer Institute (Brazil) LSTB Law and Society Trust, Bangladesh MANAS Madok o Nesha Nirodh Shansthya (Association for the Prevention of Drug Abuse) (Bangladesh) MANOBIK Madok Drabya-O-Nesha Birodi Council (Antidrug Council) MOPH Ministry of Public Health (Thailand) NCAS National Council Against Smoking (South Africa) NCCTU National Committee for the Control of Tobacco Use (Thailand) NCTU National Commission on Tobacco Use (Brazil) NGO nongovernmental organization NSRA Non-Smokers' Rights Association (Canada) NTCP National Tobacco Control Program (Brazil) OECD Organisation for Economic Co-operation and Development PAHO Pan American Health Organization PATH Canada Programme for Appropriate Technology in Health, Canada RDA Rural Doctors' Association (Thailand) RITC Research for International Tobacco Control SAARC South Asian Association for Regional Cooperation SABC South African Broadcasting Corporation SINDIFUMO Tobacco Industry Syndicate (Brazil) TASCP Thai Anti-Smoking Campaign Project (see ASH) TAG Tobacco Action Group (South Africa) TCCO Tobacco Consumption Control Office, Ministry of Public Health (Thailand) TISA Tobacco Institute of South Africa xviii ABBREVIATIONS, ACRONYMS, AND DATA NOTE TTM Thai Tobacco Monopoly UICC International Union against Canter UNICEF United Nations Children's Fund USDHHS U.S. Departnent of Health and HIuman Services WACC Welfare Association fcr Cancer C are (Bangladesh) WBB Work for a Bedter Bangladesh WNTD World No Tobacco Day WHO World Health Organization YPSA Young Power in Social. Action (Bangladesh) Data Note Unless otherwise stated, U.S. dollar amounts are given at the exchange rate prevailing at the time. Overview Joy de Beyer and Linda Waverley Brigden Countries around the world are grappling with difficult public health challenges and policy decisions. Disease and death caused by tobacco use, once a problem mainly in high-income countries, have become a large and increasing part of the burden of disease in developing countries. According to the most recent estimate by the World Health Organiza- tion (WHO), 4.9 million people worldwide died in 2000 as a result of their addiction to nicotine, about half of them prematurely (WHO 2002). This huge death toll is rising rapidly, especially in low- and middle-income countries, where most of the world's 1.2 billion tobacco users live. As shown in figure 1.1, developing countries already account for half of all deaths attributable to tobacco. The proportion will rise to 7 out of 10 by 2025 because smoking prevalence has been increasing in many low- and middle-income countries even as it is falling in richer countries, especially among men. Developing countries also account for about half of the world disease burden related to tobacco (figure 1.2). And tobacco use has far-reaching indirect effects on human health and the economy, in addi- tion to the direct harm it causes.1 But the course and pattem of this epidemic can be changed. The poli- cies that are effective in encouraging tobacco users to quit and dissuading young people from starting are well known and proven. Many countries have managed to change behavior, reduce the prevalence of tobacco use, and ease the burden of tobacco-related disease and death. This book describes recent struggles, successes, and setbacks in six countries on six continents, where the efforts of public health practitioners, researchers, activists, policymakers, politicians, and the press have achieved sound tobacco control policies even in the face of enormous opposition from those who profit from these deadly products. Reducing the devastating health damage caused by tobacco use is especially difficult because of nicotine's powerful addictive properties, 1. For studies on the prevalence of tobacco use and on the associated health and economic effects, see, for example, Murray and Lopez (1996); WHO (1997); World Bank (1999); Corrao and others (2000); Jha and Chaloupka (2000); and Mackay and Eriksen (2002). 1 2 JOY D-- 3EYER AN;D LINDA WAVERLEY BRIGDEN Figure 1.1. Deaths Attributable to Selected Leading Risk Factors, Worldwide, 2000 ____ _ _ = |Blood - _ __ ____- _] g Tcbacco pressure LI] _= Cholesterol Underwe ght U nsafe sex _ ______- Fruit and vegetable take -_0 _ ] Hl,gh body mass inde> Physical inactivity _ X ] ~Alcohlr Unsafe water, sanitation, and hygiene Indoor smoke from solid fuels Iron deficiency l Urban air pollution * High mortalily developing countries Zinc deficiency * Low mortality developing countries Vitamin A deficiency Ei Developed countries Unsafe health care injections 0 1,000 2,000 3,000 4,000 5 000 6,000 7,000 8,000 Number of deaths (thousands) Souirce: WHIO 2002. low prices for tobacco products, vsel]-established social norms, and con- stant inducements to smoke, fue]ed by billions of dol]ars worth of tobacco industry advertising and promotion. Low prices and advertising can be countered by policies that raise taxes on tobacco products and outlaw all advertising and promotion of these products. Such policies are likely to have an even stronger effect in reducing tobacco use if complemented by good public information on the associated health risks (for instance, through strong, large warnings on cigaretLe parks), by bans on smoking in public spaces, and by advice and help to people " ho want to quit. Why These Six Countries? The six countries whose stories are told in this book--Bangladesh, Brazil, Canada, Poland, South Africa, and Thailand-are at very different stages of development and o, the tobacco epidemic (see table 1.1). Brazil and Bangladesh are two to six times more pop ious than any of the other four countries. With regard to wealth and social indicatois such as child mal- nutrition and illiteracy rates, CanacLa, a developecL country, is at one extreme and Bangladesh at the other. Life expectancy at birth is consider- OVERVIEW 3 Figure 1.2. Disease Burden Attributable to Selected Leading Risk Factors, Worldwide, 2000 _ Underweight 2. lUnsafe sex ;_ Blood pressure Tobacco Alcohol Unsafe water, sanitatiori, and hygiene 111112 _ICholesterol _ I indoor smoke from solid fuels Iron deficiency High body mass index Zinc deficiency Low fruit and vegetable intake f X Pi0- i Yal Vitamin A deficiency 7MBF-I: lPhysical ihactivity | Risk factors for injury High mortality developing countries Lead exposure U Low mortality developing countries Illicit drugs E] Developed countries i Unsafe health care injections Childhood sexual abuse Urban air pollution 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000 Number of disability-adjusted life years (thousands) Souirce: WHO 2002. ably higher in Canada than in any of the other countries; it is lowest in South Africa, as a result of the ravages of AIDS. The six countries also differ in the strength and history of their tobacco control policies and in the extent to which they are succeeding in reducing tobacco use. The share of adult men who regularly use tobacco is around 40 percent in five of the countries. In Canada it is substantially lower, 27 percent, down from a peak of 60 percent in 1960 (Smoking and Health Action Foundation 2000). Male smoking prevalence has fallen significantly in three of the other countries: in South Africa, from well over 50 percent in the early 1990s to 42 percent in 1998 (Corrao and others 2000; van Walbeek 2002); in Thailand, from 49 percent in 1986 to 38 percent in 1999 (Vateesatokit et al 2000); and in the most dramatic case, that of Poland, from peak levels of 65-75 percent in the mid-1970s to 39 percent in 1998 (Corrao and others 2000). It is no coincidence that, as table 1.1 shows, compared to the other middle- and high-income countries, cigarettes are (relatively) the -D N \ oN 0, IDm0 l C),\ (Z N OONN nI \DC ~~~~~ ~ ~ ~~~~. m D DCDC NCT\ all CDNCI tzl 0CC' CD D G C CDN CD o CN N~~~~~'.0 ~ ~ ~ ~ ~ 14C ON - 0 CU u~~~~~~~U CU X~~~~~~~~~ *4- U U'* * c. 0 QD~~~~~~~~~~~ CD u ~ ~ ~ ~ ~ 0 C,4~~~~~~ 0 C) 0 b" C) Oll ON Qi 'KI 'I; ::s 'a 0 E bc LO N LO r. C)0 < "I u u U m ci a) all OC) CD Go 't tz! M. CD 'IV C14 ro - tzt CON tlo 0, r-4 N u o, Z r _C; 'Z 2 ra LO CO 'D :-z" CD Lr) Lir) -- Ln Lr)M-u 00 00 CC", cis C C) u c'i I GI 2 u 0 ci :j r_ Z C) Cl. v ai 0) 0 C) Lr) M Co .D .o C7, Lo r, 0 u :3 00 C14 CD Mt .Cr,) ci C: 'u' 2'cE3 CD C-4 C) r) u 0 V) ci CS -0 C) -0 C) r Lr) -0 r. _x cn -0 -0 C) I Cy, 7 r 0 N CL, -C C; o' s u > 11 0 u U a) -cl > q M 0 -0 M M C) 'Zi cu I 0 -o 6.0 -0 0CD bio M C) u 4, C) C) cl) ci u LO u 0 0 C) C) 4.1 C) c) o ra 7s -tc CD -w  I,. C) 14, 14, CO r4 0 0 M cn C; M u, 0 to r4 U) cq M w - M M r, " mw C VI 0 u r- cu a)0 0 q r; 6 "I cj mu C) 6 JoY 111 Bi Yt R A, N)D LI.\DA 'VVAVFR1.EY BRIGDFN least affordable in Poland, whcrc a F e-sori eaniing the average wage must work for about 40 m inute,s to e,- n the priee of a pack of cigarettes--roughly twice as long as in the otl ter folr Cot uri-,, iirt the sam ie or high income cat- egory (Guindor, Tobirn, and Yac i 2002). In laanyladesal, very low wage rates make cigaretles least affoidable of a] the couLnh ries, e\en though the prices (of local brands) are amonig the lowest. This is a very heterogeneous group ef coUntries But there is a com- mon thread: alL six have achirved notabl. succeszes in tobacco control policymacking by builcliiig advocacy on s.ouuid reeLarch and evidence. Their stories exemplify irrporiarut featuni- of policymaking, particularly the significant role that can be played by determined individuals and by civil society groups. The stories make it clear that the-e is 10n m igic formula. Instead, they tell of policy entrepreneur-s (King,don 1995)--bath individuals and groups-willing to champion the is!iue; ol politicians committed to pub- lic healtlt and to placing toaacco control on- the policy agenda; of researchers who have published and publicized compelling national or international data; and of national, regienral, and i iternational political, social, economic, and policy enviroinmnents tha-vt suLpported action on this important issue. Many other countries, or states and provinces \ithin countries, have achieved admirable successes in tob,icco contr:ol policvmaking and could have been incliuded in this book, were itr not for the limitations of space. We hope that the inspiring experiences oF othier co. ntries will be related elsewhere. Each country includecl in this book -ias s:)me extraordinary accom- plishments in tobacco cointrol policy and its ovn particular strengths. In Bangladesh systematic, concerted, and m2thodical e ffor-ts by nongovern- mental organizations (N(XG)s) prvi)\'.ic rncdel of very low-budget but effective advocacy against what seeiried tLo be mnpo,sible odds. In Brazil, by contrast, persistent action led roum wiithin the government resulted in strong legislation and a rictionrwic e, decen t-ali aed program, with training and suppert cascading, dcwn the levcls ,of go\vrrnnerit. Canada has long been c world leadler in t.obc ceo control legislation, tax- ation, and healr:h warimnin's, backed by sn oicg citi/en and political sup- port. It providLes a model of coalit on buildngt dtmg ron civil society groups that resulted in wvell-p anned, sys en)atic av\ ocacy initiatives. In Poland and South Africa diarratic anolit cal aEld social change cre- ated new environments and policv \\ inclov, s th-at pLiblc health advocates were able to turn to their idvarta-.e. In the l1,99's th'-se countr-ies enacted, relatively qui-ky, strong, comrprehcrisive legislation--in both cases, in two legislative steps, withl a second Il\''v strentgt aeoing the first. Both coun- tries began with policies to betto2r inform consumriers and to restrict smok- OVERV FeW 7 ing and advertising. At a later stage, tax increases were put in place and helped reduce consumption. Each country had strong, charismatic cham- pions who helped drive tl-he issue, through undaunted, persistent efforts over many years. And in both countries the availability of strong local research evidence, especially on the economic implications of tax increases, was enormously important. In Thailand, as in Bangladesh, an NGO played a pivotal role. Tobacco control policy has beent significantly influenced by strong advocates in the health sector with direct access to governmenl officials, sorne of wh1om showed great political couragc, inlegrity, and commitment Lo serving the best interests of the Thai people. Although all of the stories describe setbacks and disappointments, none of them dwells on mistakes made or opportunities riiissed, or on what could have been done bctter. There are lessons to be 1earrned from both the successes and tlle setbacks in each country. The stories describe how advocates and policymakers changed their strategies in certain coun- tries as they Ieamed from their mistakes and built on their- achievements. What Factors Made the Difference? Although each country's situation and story is unique, there are com- monalities across the six countries-lessons and experiences that arc also applicable in other contexts. * In each case, legislative successes were won in the facc of vigorous opposition from a tobacco industry striving to defend its profits and market. Sometimes the legislation was wcakened or deLayed or its implementation was inhibited. Compromises had to be made, but these sometimes paved the way for stronger follow--up laws a few years later. * Time and again, a key role was played by NGOs and by individuals- often very charismatic people--who showed extraordinary commit- ment and dedication. Through their knowledge and perseverance, they became credible spokespersons for their cause and won the ear of policymakers. * Coalitions of individuals and organization-s brought new skills anld perspectives to bear on the issue Broad-based groups such as con- sumers' rights groups, development agencies, women's riglhts activists, lawyers, and religious organizations made important contribtitions. Personal and institutional objecLives and prestige were sometimes set aside for the sake of achieving common goals. Groups had to grapple with the organizational and relationship issues that are part of main- taining a smoothly functioning coalition. Not all coalitions survived. 8 JOY DE BEYER AND LINDA WAVERLEY BRIGDEN * Effective advocacy has to be lean-ed. Tobacco control advocates found that change is a slow, evolutionary process, they learned to expect set- backs and make use of them to turn defeats into victories; to take advantage of favorable opportunities as they arose, developing rapid- response, short-term strategies as well as long-term goals; and to be creative in seeking allies. No: least, they leamed about the need for optimism and for a continuous, sustained effort. * While much can be done with little money if finds are used wisely, lack of an organizational home and a mi-nmal level of financial resources can make it hard to operate effectively. Working collabora- tively with national and international agencies can help provide access to sustained, if limited, resources. * Strong political support and political champions are absolutely crucial to success. At times, political champions have hail to persuade and win over (or prevail over) their own colleagues. Public opinion polls have been influential in some countries, demonstrating to politicians clear popular support for strong policies to protect children and adults from the harm caused by tobacco use. * Amazing transformations in social n-orms can occur, spurred by changes in legislation, shifts in the sccioeconomic context, and better public information. This is starkly evide,nt to anyone who choked through meetings in smoke-filled rooms in Poland in the late 1980s and has had the pleasure of visiting Poland again in recent years and enjoy- ing smoke-free meetings and meals. The media can have a powerful effect in influencing popular Dpinion and paving the way for legisla- tion. Legislation both reflects and reinforces--or institutionalizes- changing social norms. * An understanding of the political framework and the legislative timetable of the country contributes to effective advocacy. That under- standing might involve knowing when to intervene and whom to tar- get; cultivating legislators who are favorably disposed to an issue; or recognizing when an idea's tirme has come and responding swiftly with information and advocacy. * Legislation must be coupled with strong attention to implementation and enforcement. This can be an even greater challenge than getting the legislation through with its teeth intact. Often, legislation is only a first step, and regulations or further actions are required before provi- sions can be implemented and take effect. * Sound research and evidence are extremely important as a basis for good policy decisions. Evidence and research findings from other countries can be compelling, but there is also likely to be a need for strategic, selective local stucies and data, prcsented concisely and graphically. Building, publish ng, and widely publicizing a solid infor- OVERVIEW 9 mation base proved enormously useful to policymakers and advocates and helped promote changes in public attitudes and awareness that gradually led to changes in social norms in several countries. * Tobacco control policies and strategies must be comprehensive. It is now well recognized that single initiatives are not enough; real impact comes from a combination of education and information, legislation, taxation, community action, professional involvement, prevention and cessation programs in various settings, prohibitions on smoking in public places, and complete bans on advertising and promotion of tobacco and tobacco brands. * Strong, effective tobacco control policy that includes tax increases and complementary health promotion efforts relies on success in bringing together diverse interest groups and finding common ground. This is especially important with regard to the ministries of health and finance, whose objectives of sound fiscal management and better pub- lic health outcomes can both be furthered by tobacco tax increases. * Not all policymakers were won over by data on tobacco-related mor- bidity and mortality. In Bangladesh reframing the issue to focus on the contribution of tobacco use to malnutrition was what captured the attention of policymakers. Donor agencies may be more interested in and willing to support tobacco control to the extent that it contributes to and relates to broader development issues. * Not long ago, in some countries, the situation seemed hopeless. Efforts by poorly funded public health groups were opposed by tobacco com- panies with powerful political connections and deep pockets. Social norms favored smoking, and many people were skeptical about or even hostile to tobacco control efforts. But, as in Canada, public health proponents discovered that "seemingly irresistible forces within the tobacco industry could be successfully challenged by effective advo- cacy" (Sweanor and Kyle, ch. 4 in this volume). * Persistence is essential. Never give up. The Big Picture Each country profiled in this book has recorded great progress and sub- stantial achievements in tobacco control policy. But in none of them is vic- tory assured, and in none has the war against misinformation, ignorance, addiction, preventable disease, and premature death been won. Smoking still claims too many lives, and too many teenagers are enticed into trying "just one" and then another, starting what will become a deadly addiction that most will regret ever taking up and will later struggle to break. This is an important time-perhaps a watershed-in the history of tobacco control policy and of efforts to curb the epidemic caused by 10 Joy iDF BEYER i,\1) IJND,I WAVERIEY BRIGDEN tobacco use. The negotiations for an nterriatioi ial Framework Convention on Tobacco Control (FCTC) have provided an important forum and process, enablinlg each of the 165 participating, countries to weigh com- peting national interests carefully and decidc hos\ strongly committed they are t-o measures that can improve health outcomes by reducing tobacco use. The challen-ge that lies ahead for countries is to ratify the FCTC and to strengthen national legislation, policies, and programs and international cooperation to reduce tobacco use. Sometimes the discussion abcut tobacco contro is framed as health versus economics, with people conceding the harm that tobacco does to health but emphasizing the economic contributions of the tobacco indus- try in the form of jobs, mncomes, exports, and tax revenues. The relative economic importance of the tobacco industry, however, is often exagger- ated, and the economic costs of tobacco should also be considered. These costs include the direct and indirect costs of m edica care; the loss of pro- ductivity and earnings as a result of tobacco-related illnesses and deaths; environmental degradation caused by pesticicles and the use of firewood for curing tobacco; and fires caused 3y lit cigarettes and matches. Perhaps most insidious is the harm done to poor smokers and their families by the diversion of scarce family incDme lo buy tobacco prod- ucts. The chapter on Bangladesh presents detailed data on the opportu- nity cost of tobacco purchases, comparing the cost of cigarettes with the costs of food staples that the money spent on cigarettes might have bought-this in a country where perhaps half of all adults smoke or chew tobacco while nearly half of Eall childreni uncer five are malnour- ished. As Efroymson and others '20D1) have showrv, "Each tobacco user represents one or more people--whethei- the smoker or his or her spouse or child-who is neediessly going hungry."' All-hough this situation is not well documented in many other coantries, it is certainly not unique to Bangladesh; for example, women- in a poor village in Sri Lanka said that cigarettes were the leading cause of povertb, in their village (Skolnik 2003). National surveys of household expenditure find that in Egypt and India 2 to 3 percent of all household expendil.ures go for tobacco prod- ucts; in South Africa, families that incluce at least Dne smoker and that are in the lowest income quartile spent 4.7 per(ent of their income on cig- arettes in 1995 (Basheer 1993; van WNalbeek 2000; Sayginsoy 2002). For families living on the edge of pover-y, even small amounts can make an enormous difference to family well-being. It is thus misleading to frame thie tobacco control debate as "health ver- sus economics." Tobacco generates ircorne for -,ome aut entails large costs for others. Tobacco control is clearly key to promcting health and pre- venting unnecessary deaths, ancl it can be a chieved in the context of OVERVIEW 11 sound economic and social policies, without harming economies. Brazil's discussions with tobacco farmers and its initiatives to work with them are a case in point. Tobacco is clearly much more than a health issue; it has significant eco- nomic implications and can have an impact on economic development. Improvements in health can contribute to sustained and substantial improvements in social and economic well-being, as the WHO Commis- sion on Macroeconomics and Health (2001) recently emphasized. Con- versely, poor health can undermine social and economic development. The broader development issues relating to tobacco and its control have been much discussed in the FCTC deliberations. The FCTC has the poten- tial to provide a common framework allowing countries to move ahead together to reduce tobacco use, mindful both of those-particularly among the poor-who will benefit and of those whose livelihoods may be jeopardized if national and global markets for tobacco decline. Global partnerships, both explicit and implicit, can work to the com- mon good of citizens in all countries. There is great value in comparing notes with other countries, learning from their successes and mistakes, and borrowing their data. Governments often hesitate to step out ahead of the pack but can be emboldened by the actions of others, as shown by the domino effect of changes in tax policy, advertising bans, and the recently introduced large pictorial health warnings on cigarette packs. We hope that this book will help inspire and inform tobacco control activists, public health practitioners, policymakers, and citizens who care about their health and the futures of their children, so that more can be done to reduce the harm that tobacco does to health and lives around the world. References Bangladesh Bureau of Statistics. 2000. Statistical Yearbook of Balugladesh, 2000. Dhaka, Bangladesh. Basheer, R. A. 1993. "The Economics of Tobacco and Its Consumption in India." Report prepared for the World Bank. Washington, D.C. Processed. Commission on Macroeconomics and Health. 2001. "Macroeconomics and Health: Investing in Health for Economic Development." World lHealth Organiza- tion, Geneva. Corrao, M. A., G. E. Guindon, N. Sharma, and D. F. Shokoohi, eds. 2000. "Tobacco Control Country Profiles." American Cancer Society, Atlanta, Ga. Efroymson, D., S. Ahmed, J. Townsend, S. Alam, A. Dey, R. Shah, B. Dhar, A. Sujon, K. Ahmed, and 0. Rahman. 2001. "Hungry for Tobacco: An Analysis of the Economic Impact of Tobacco Consumption on the Poor in Bangladesh." Tobacco Control 10 (3): 212-17. Available at . 12 JOY DE BEYER AND LINDA WAVERLEY BRIGDEN Guindon, G. E., S. Tobin, and D. Yach. 2002. "Trends and A fordability of Cigarette Prices: Ample Room for Tax Increases and Related Hiealth Gains." Tobacco Control 11 (1): 35-43. Available at . Health Canada. Cancer Surveillance On-Line. Available at . Jha, P., and F. J. Chaloupka, eds. 2000. Tobacco Cooitroi in Developing Countries. New York: Oxford University Press for the World Bank and the World Health Organization. Kingdon, J. W. 1995. Agendas, Alternatives, anld Pubiic Pol,cies. 2d ed. New York: HarperCollins College Publishers. Mackay, J,, and M. Eriksen. 2002. The Tobacco Atlas. (leneva: World Health Organization. Murray, C. J., and A. D. Lopez, eds. 1996. The Globa Burd?n1 of Disease: A Compre- hensive Assessment of Mortality and Disabi'ityf-om D ^seases, Injuries and Risk Factors in 1990 and Projected to 2020. Cambridge, Mass.: Harvard School of Public Health. Saygmsoy, 0. 2002. "An Analysis of the Links betvween P'overty and Tobacco in Egypt." World Bank, Washington, D.C. Processed. Skolnik, R, 2003. Personal communication. Smoking and Health Action Foundation, Canada. 2000. "Framework Convention on Tobacco Control. An International Instrument to Deal with an Interna- tional Problem." Submission to the World Health Organization. Available at Non-Smokers' Rights Association Website, ; accessed February 25, 2003. van Walbeek, C. P. 2000. "The Distributional Impact of Chamges in Tobacco Prices: Some Preliminary Findings." Economics of Tobacco Control Project (Phase II). University of Cape Town, South Africa. Frocessed. . 2002. "The Economics of Tobacco Contr-ol in South Africa." University of Cape Town, South Africa. Vateesatokit, P., B. Hughes, and B. Ritthphakdee. 2000. "Thailand: Winning Bat- tles, but the War's Far from Over." Tobbicco Control 9(2):122-7. Available at . WHO (World 1HIealth Organization). 1997. "TobaccD or Hlealth: A Global Status Report." Geneva. . 2002. The World Health Report 2002: Reducing Risks. Promoting Healthy Life. Geneva. World Bank. 1999. Curbing the Epidemlic: Governmnenis and the Economics of Tobacco Control. Development in Practice series. Wash ingtor,, D.C. . 2002. World Developmnent Indicators 2002. Washington, D.C. Selected por- tions of the database are available at . 2 Building Momentum for Tobacco Control: The Case of Bangladesh Debra Efroymson and Saifuddin Ahmed Bangladesh is a small, poor, densely populated country of roughly 130 million people, about 80 percent of whom live in rural areas. It has a well- deserved reputation as being disaster-prone, having been stricken with droughts, floods, and a range of health and environmental problems, from dengue and cholera to arsenic contamination of the water supply. It should come as no surprise, then, that tobacco control has not gained much attention or been considered a priority. With so many competing causes of disease, and with nearly half the population living below the poverty line and consuming less than 2,122 calories per day (Bangladesh Bureau of Statistics 1998a), tobacco has generally seemed too remote and insignificant an issue to be on the country's agenda of concerns. Yet tobacco use is widespread and increasing rapidly, and knowledge about the harm it causes to health is slight. Moreover, although other causes of death still dominate, tobacco use contributes a nontrivial amount to the overall burden of disease and death. And it has clear and significant immediate negative effects on the welfare of poor families, when scarce resources that could be used for food are instead spent on tobacco. From the late 1980s through most of the 1990s, tobacco control remained the domain of a few groups: Amra Dhumpan Nibaron Kori (ADHUNIK), which, roughly translated, means, "We prevent tobacco"; the Bangladesh Cancer Society; Madok o Nesha Nirodh Shansthya (MANAS-the Association for the Prevention of Drug Abuse); and the National Non-Smokers' Forum. Although these groups achieved some significant successes, for the most part tobacco control remained a fringe activity that received wide publicity on World No Tobacco Day, May 31, and was then forgotten for the rest of the year. But in 1999 the tide began to turn. The aggressive activities of British American Tobacco (BAT) pushed the advocates toward stronger action. For the first time, a number of organizations got together and coordinated 13 14 DEBI'A EFROYMSON AND SAIFUDDIN AHMED their activities. A coalition emerged, a High CDurt victory was obtained, and tobacco control in Bangladesh finally began to assume some of the importance and receive some of the attentLion it had long warranted. By late 2002, strong new legislation had been submitted for consideration by Parliament. This case study discusses the cdynarnic process of tobacco control policymaking in one developing country and the rc,le that advocates can play in informing and influencing the process. The ultimate goal has not yet been reached, but the journey has begun. Tobacco in the Lives of the Banigladeshi People Although Bangladesh is a Muslirn country and tobacco is generally con- sidered haram (forbidden) under Islam, tobacco use is widespread. The Bangladesh Bureau of Statistics regularly conducts surveys that monitor, among other things, smoking rates. As table 2.1 shovvs, smoking rates are higher among men than women. In 1997 the highcst reported rate (70.3 percent) was for men age 35-49, while the lowest (0.1 percent) was for girls age 10-14. A significant flaw in the prevalence measures is that they cover only smoking, not tobacco consumption as a whole. Tobacco chewing is com- mon in Bangladesh, particularly among women. A study by Naripokho, a nongovernmental organization (NGO) warking on women's issues, indi- cates that the rate for use of all forms of tobacco, smokeless and smoked, by women is around 50 percent, but no nationwide or large-scale surveys exist to verify this finding (Haq 2001t). According to data compiled by the World Health Organization (WHO) on tobacco and cigarette production and consumption in Bangladesh, an estimated 70 percent of the tobacco produced is used for cigarettes and bidis (small cigarettes handrolled in paper), 20 pe-cent is consumed as chewing tobacco, and the remainder is used in cigars, snuff, and pipe tobacco. In 1997, 16,500 million cigarettes were manufactured, consisting Table 2.1. Smoking Rates by Age and Sex, Bangladesh, 1997 (percent) Ag Sex 10-14 15-19 20-.34 35-49 50- Male 2.8 14.4 47.6 70.3 21.2 Female 0.1 0.9 3.3 6.6 2.8 Average for both sexes 1.6 8.3 23.7 41.0 12.3 Souirce: Bangladesh Bureau of Statistics (1999). BUILDING MOMENTUM FOR TOBACCO CONTROL 15 of 2,900 million filter and 13,600 million nonfilter cigarettes. Since the mid-1980s, Bangladesh has had a growing negative trade balance in tobacco and tobacco products as leaf imports have increased strongly (see table 2.2). In 1993 export earnings amounted to US$10 million, half of the US$20 million that was spent on tobacco and tobacco product imports. By 1995, according to the World Bank, the negative net earnings from tobacco trade (leaves and cigarettes) had nearly tripled, to US$27.8 million. Although tobacco is available in a multitude of forms in Bangladesh, only cigarette packages carry a warning. This states (in Bengali), in small type, "Government warning: smoking is deleterious to health." The same warning is used on BAT billboards and on television advertisements but not on advertisements for cigarettes produced by other companies or for bidis. What little information is conveyed in the warning is inaccessible to Table 2.2. Annual Tobacco Trade and Agricultural Statistics, Bangladesh, Selected Years, 1970-98 Indicator 1970 1980 1990 1995 1998 Cigarette imports (millions of sticks) - 177 86 70 52 Cigarette exports (millions of sticks) - - 2 - 47 Tobacco leaf imports (metric tons) - 740 805 1,137 5,012 Tobacco leaf exports Metric tons - - 870 278 2,307 Percentage of total exports - - 0.11 0.02 - Cigarette production (millions of sticks) 17,787 13,830 12,289 17,379 - Tobacco leaf production (metric tons) 41,200 39,524 37,800 38,000 36,655 Land devoted to growing tobacco Hectares 45,700 45,091 45,070 36,000 32,823 Percentage of agricultural land 0.50 0.49 0.48 0.44 - Employment in tobacco manufacturing (number of workers) 4,190 6,340 27,155 - - Not available. Source: Corrao and others 2000. 16 DYBRA EFROC"iMSON AN Da SAIFUDDIN AHMED the large proportion of the popuLlation Lilable to read. According to the Bangladesh Bureau of Statistics (I 999), in 199, only 42 percent of females and 51 percent of males over age 7 were literate. The law has yet to set a standard for informing tobacco users about the range of diseases caused by smcking and tobacco use. One study found that while more than 93 percent of rrale smokers andl more than 84 percent of female smokers know that smokirg is generally bad for health, far fewer are aware of specific eFfects such Es cancer, respiratory diseases, stroke, and heart disease. In general, nonsmokers have slightly higher awareness of the diseases caused by smoking than do smolkers (Bangladesh Bureau of Statistics 1996). Although the lack of nationwvide statistics on tobacco use makes track- ing the epidemic difficult, a few fccts are clear. Tobacco use (as distin- guished from smoking) is widespread amon-g men and women. Most users are not aware of the health effects, and wlritten warnings can be read by only about half the population. Better statistics are needed to track tobacco use among the population and to monitor c(hanges when tobacco control laws and interventions come into effect. The Tobacco Industriy in B2nglcdesh The Bangladesh Tobacco Comi any (13TC) operated essentially as a monopoly for many years. It was originally a subsidiary of BAT, which has been doing business in Banglacdesh since 1954. In the late 1990s BAT bought controlling shares in the BTC, which then began operating directly as BAT. BAT reported pretax profits in 1998 of UJS$ [5.4 million and had a bud- get of US$3.34 million for brand promotion and development (BAT 1998). This huge promotion budget explains the ubiqui'dous presence of BAT brands (mostly Benson & Hedges and John ['layer Gold Leaf and, to a lesser extent, 555) on billboards, in rewspaper advertisements, and in cig- arette display cases, as well as in television advertisements and at con- certs sponsored by Benson & HIedges. BAT advertises its cheaper brand, Star, less widely, mostly on inexpensive posters on the street. About 15 local corrmpanies also produce cigaTettes, which are less expensive than BAT's. The largest manuifacturer of bidis is Akiz Bidi, which also produces the Navy brand. Various cheaper brands are adver- tised to some extent through posters, on small signs in shops, and in dis- play cases, bu+ Navy is the only non-BAT brand for which there is any extensive advertising. Researchers monitored the advertisements on ATN Bangla (a Bengali- language Indian satellite television station) from E p.m. to 10 p.m. on a Saturday evening, a time when young people are fairly likely to be watch- BUILDING MOMENTUM FOR TOBACCO CONTROL 17 ing television (Shaha, Dhar, and Efroymson 2000). During the two-hour period, they counted 38 tobacco advertisements, covering 14 minutes and 13 seconds. There were advertisements for two different brands of bidis and seven different brands of cigarettes. Ten advertisements for Navy brand ran during the two hours. Many of the advertisements conveyed the message that smoking makes one strong, healthy, and irresistible to women. Two examples illustrate the point: * An oxcart gets stuck in the mud, and the driver is unable to push it out. A young man approaches, watched with great admiration by a pretty peasant girl. He takes a few puffs of a cigarette, then pushes the oxcart out of the mud and offers a cigarette to the driver. The girl is in ecstasy. * Mr. Navy rescues a young woman from drowning. She turns out to have been faking the incident, but she wins his affection by calling him back to retrieve the pack of Navy cigarettes that fell from his pocket while he tried to resuscitate her. They frolic on the beach, then stand lovingly while he smokes. These advertisements carry a health warning in Bengali, but it is flashed briefly either at the beginning or the end of the ad, so quickly and in such small type that it is virtually impossible to read, even by the half of the population that is literate. In any case, it simply repeats the statu- tory warning that is printed on cigarette packs: "Smoking is deleterious to health." The High Court of Bangladesh, in response to a petition brought by members of the Bangladesh Anti-Tobacco Alliance (BATA), recently held that this mode of flashing the warning is in violation of the law. The court went on to say that all tobacco advertising should be banned. The case is currently on appeal. As part of its attempt to resist regulation, BAT has promoted itself as a responsible company. It has done this in several ways: * In 2001 the company issued a voluntary code of conduct that limited tobacco advertisements on television and radio to the hours of 10 p.m. to 6 a.m. (BAT 2000). * BAT claims that it offers samples only to smokers or tobacco users over 18 years of age. * In newspaper advertisements and in programs distributed at cultural events sponsored by BAT, messages such as "Our events promote more than just our brands" are displayed. * A tree nursery program supported by BAT has brought the company much positive attention. The minister of the environment has visited the Dhaka nursery, and the trees and accompanying advertising signs line some medians in Chittagong, the main port city. In August 2001 18 D1EBRA EFROYMSON AND SAIFUDDIN AHMED BAT set up highly pub]icized roadside stands in Dihaka to hand out tree saplings. On July 28, 2001, BAT launched a so-called Youth Smoking Preven- tion Campaign consisting of 30-second televi ,ion advertisements, three 1-minute radio scripts, billboards, and stickers. In all the mate- rials, BAT claimed that smoking is an adult chcice, that those under age 18 should not smoke, ancl that BAT feels a responsibility to cur- tail and prevent youth smoking. More astute yo ing people easily see through this campaign and recognize the contradiction between the company's heavily advertising its branlds and yet telling youths not to smoke (WBB and PATH Canada 2001). For many, however, the campaign seems to offer evidence of how responsible and well- meaning BAT is, and it provides a further excuse for the inaction of lawmakers who wish to avoid passing tough laws to control tobacco. The Economics of'Tobacco in Bangladesh The government of Bangladesh has sent mixed messages about tobacco. Former prime minister Sheikh Hasina has said that tobacco spending is a waste of money and that redirecting the money spent toward food pur- chases could lower the rate of malnutrition (BATA 2001). Yet Hasina's gov- ernment awarded BAT a trophy for being oiie of the country's largest exporters. BAT is apparently the biggest taxpayer in the country, with reported tax payments in 1998 of approximately US$5.55 million (BAT 1998). But export earnings and tax payments do rot provide a complete eco- nomic picture of the tobacco industry in Bangladesh. Missing are such items as the trade deficit, the costs associated with tobacco-related health problems, and the effect of smokers purchasing tobacco rather than food. In fiscal year 1997-98 Bangladesh earned IJS$5.4 million in tobacco exports, but it also imported US$,19.93 m-i]lion worth of tobacco, for a net loss of over US$14.4 million (Bangladesh Bureau of Statistics 1998b). Although figures on health costs associated with tobacco use are not available, the Bangladesh Cancer Society estirmates :hat half of the annual deaths from cancer in Bangladesh (75,000 people) result from tobacco use. The tobacco industry also hes an effect on employment. Cigarettes require very little labor to manufaclure. Bidi rolling is much more labor- intensive, but most of the profits are ab,orbcd by middlemen, with the laborers, almost exclusively women and childIren, earning a pittance for their many hours of grueling work in uncom fortable and unhealthy set- tings (UNICEF 2000). According to the World Bank (1999), because most goods and services in Bangladesh require a Lirger labor input than ciga- rettes, a shift from tobacco product use and manufacturing to other prod- ucts and services could mean a tremendouas boon for employment. BUILDING MOMENTUM FOR TOBACCO CONTROL 19 Although tobacco is perceived as being cheap, its actual cost, compared with food, education, and health care, is quite high-exorbitantly so for those for whom basic survival is a daily struggle. A study on tobacco and poverty (Efroymson and others 2001) revealed that tobacco is most com- monly used by those who can least afford it. The smoking rate among the poorest (those with a household income of less than US$20 per month) is 58.2 percent, while for the wealthiest (those with a household income of more than US$100 per month), it is 32.3 percent. On average across the country, spending for tobacco represents 2.8 percent of total income, from a low of 1.5 percent for households with total spending of less than US$18 per month to a high of 4.4 percent for households spending more than US$472 per month. The amount spent by the average male cigarette smoker in 1997 would purchase 2,942 calories of rice per day-enough to make a difference between family members getting by or suffering from malnutrition. Between 1992 and 1996, annual per capita cigarette consumption increased by 33 percent, from 100 to 133 sticks. Meanwhile annual per capita egg consumption fell by 29 percent, from 17 to 12 eggs. In other words, per capita consumption in 1996 was 1 egg and 11 cigarettes per month. Average per capita expenditure on tobacco is almost half per capita expenditure for health, and more than half the amount spent on education. In both urban and rural areas, per capita expenditure is higher for tobacco than for milk. At 2000 prices, the money needed to purchase one pack of BAT's John Player Gold Leaf regular cigarettes would buy more than a dozen eggs, or more than a kilogram of lentils, or more than a liter of soybean oil, or half a kilogram of beef. BAT Bangladesh's gross turnover in cigarettes for 1998 (US$293 million) could have purchased 4.7 billion eggs, or enough to feed almost 13 million children one egg per day (Efroymson and others 2001). Efroymson and others (2001) estimate that 10.5 million children who are currently going hungry would have enough to eat if their parents redirected 69 percent of their tobacco expenditures to food. Malnutrition wreaks havoc on the Bangladesh economy: UNICEF (1998) estimates that lost lives, dis- ability, and productivity losses caused by malnutrition cost Bangladesh the equivalent of more than 5 percent of its gross national product. So far, research and publicity have not sufficiently impressed on policy- makers and the public the negative economic impact of tobacco use in Bangladesh. As long as BAT is able to convince policymakers that the company is a positive factor in the economy, advocates are unlikely to succeed in obtaining strong tobacco control laws and policies. Whatever the features peculiar to Bangladesh, in many ways the tobacco situation is like that in many other countries, particularly those with a similar economic status. The tobacco industry, as in most countries, is dominated by a transnational company; tobacco use is widespread, as 20 DEB {A EFROYMSON AND SAIFUDDIN AHMED is ignorance of the effects of its use; anc policymakers and civil society have a distance to travel to recognize the harmn that tobacco does and to be convinced of the need for tobaicco control legislation. A Chronicle of Tobacco CorLtrol in B3angladesh Until recently, tobacco control acvocacy and activil-ies were limited, and hopes and aspirations concerning the issue M,ere g2nerally modest. This was partly because of the many hea]th problerms thc t face Bangladesh but perhaps also because public health advocates felt overwhelmed and dis- couraged in the face of BAT's enormous influence, resources, and visibil- ity. Then the industry went too far and spa rkei an extraordinary reaction, the outcome of which has given niew hope and a new impetus to tobacco control efforts. In the following necessarily simnplified account, the key role played by various NGOs in studying the problem, prormoting solutions, and influ- encing key players is evident. The government ard the judicial system have also played a critical part, as have the media and the general public. Early Concer,i aboutt Tob,qcco Use Although the issue of tobacco use has a ways attracted some interest in Bangladesh, it has mainly been perceived as a problem only by people concerned about cancer and drug use. Tobacco control was taken on by a few isolated groups with no real sower to change society or public policy. And as long as tobacco use continued to be perceived as an issue of minor importance, a strong policy response was unlikely. The dominance of doctors in tosaccc, con trol organizations kept the focus mainly on health, with little attention to the nonhealth dimensions of the epidemic such as the direct and ind irect costs of health care, includ- ing lost earnings. Tobacco control efforts mos-tly concentrated on school programs and the organization of rallies and other small-scale events on World No Tobacco Day. The emphasis on talking to schoolchildren with- out taking other steps to address acult tobacco use may even have unin- tentionally attracted young peop e to using tobacco. In any case, the unso- phisticated tobacco control messages were no match for glossy, attractive tobacco advertisements, particularly those of 3AT. One of the pioneer organizations involved in tobacco control was ADHUNIK, founded in 1987 by National ProFessor Nurul Islam. 1. "National Professor" is an honorific title conferred by [he government. BUILDING MOMENTUM FOR TOBACCO CONTROL 21 ADHUNIK representatives held many seminars and press conferences, published information in newspapers, appeared on television, printed information about tobacco and Islam for distribution to Muslim religious leaders, and contributed to the syllabus for class 8 in Bangladeshi schools. They also succeeded in making the president's residence a non- smoking establishment (ADHUNIK 1988). Some other organizations have worked on tobacco control for many years. Among them are * The Bangladesh Cancer Society, which has long attempted to raise con- cern about the issue of tobacco use, mostly through school campaigns and programs highlighting the connection between tobacco and cancer. In 1995 the Cancer Society also printed a booklet that discussed the economics of tobacco in Bangladesh, including the viability of alterna- tive crops (Ahmad 1995). * MANAS, started in the 1990s by Dr. Arup Ratan Chowdhury, a well- known dentist and singer. Its main activity is conducting school cam- paigns and seminars, as well as presenting programs on television. * The National Non-Smokers' Forum, founded in 1986-the first anti- tobacco organization in Bangladesh. It publishes a quarterly newsletter and undertakes various public relations activities such as running sem- inars and workshops and printing informational materials. These organizations are still active, both independently and in collabo- ration with BATA, whose founding is described in the next section.2 Before 1999 most of these groups focused on awareness-raising activi- ties, particularly on health and for school-age children. What was missing was a determined effort to urge the government to pass strong tobacco control legislation, as well as the information and research needed to demonstrate the multisectoral nature of the problems of tobacco use. The Catalystfor Change It was a specific marketing campaign by BAT that finally provided the impetus for a concerted and courageous effort by tobacco control advo- cates. Even though advocates had become used to the flashy, sophisticated 2. ADHUNIK and the Bangladesh Cancer Society played an active role when BATA was first formed. As a result of internal politics, ADHUNIK is no longer active in BATA, and the Can- cer Society has formally withdrawn. In April 2001 ADHUNIK announced that it was form- ing its own alliance, the Coalition Against Tobacco (CAT). 22 DEBRA EIROYAISON AND SAIFUDDIN AHMED cigarette advertisements on television, in newspapers, and on billboards throughout the country, BAT's Voyage of Discov,ry campaign in the sum- mer of 1999 was startling. The idea of sailing Et yacht carrying the John Player Gold Leaf brand logo to 17 countries in L77 days caught people's imagination. The excitement was enhanced by the clhoice of the port of Chittagong as the final destination. Alarming as were the billboards, nelwspaper acdvertisements, and cigarette display stands embossecd with the Voyage colors and its slo- gan "Go for the Adventure," more worrisome were the lengthy and highly sophisticated television advertisements on the national TV sta- tion, Bangladesh TeleVision (BTV). Despite a law prohibiting BTV from carrying tobacco advertisements, the station repeatedly broad- cast advertisements for the Voyage. This b]ata it disregard for national law in pursuit of profit, and the national fervor about the Voyage, caused a wave of unprecedented concern about tcbacco control. But the concern was mixed with a sense of despair, as there seemed little that tobacco control advocates could do in the face of the wealth and power of BAT. In July 1999 Work for a Better Bangladesh (W13BB), a new organization devoted to tobacco control and urEan environmental issues, organized a meeting to discuss possible responses to the Voyage campaign. Although only one other organization, the National Non-Smokers' Forum, was represented at this first meeting, the WBB was not deterred. What these tobacco control advocates lacked in wealth and po-wer, they more than made up for in persistence. WBEB staff contacted other organizations that might be interested-groups working on cdrug problems, develop- ment, consumer issues, and women's issues--and continued to orga- nize meetings. Gradually attendance increased, and BATA was born. The WBB, on behalf of BATA, organized a press conference at which dignitaries, including Nurul Islam, founding presicLent of ADHUNIK, spoke. At a seminar organized by BATA, a range of organizations pre- sented their views, and barrister Tania Amir of the firm Law Associates offered her ideas on legal remedies that were unlikely to succeed but were worth trying in the absence of other possibilities. (Amir later founded Law and Society Trust, Bargladesh-LSTB-a member orga- nization of BATA.) Besides attracting advocates to the cause, B &TA 'aced the challenge of raising funds for its activities. Most of t:he groups in BATA were small and had limited funds, and the larger organizations faced administrative difficulties in committing a significant arrioum of money for advocacy work. To overcome the hurdle, all of the organizations involved agreed to contribute small amounts; PATH Canada provid ed further financial assis- BUILDING MOMENTUM FOR TOBACCO CONTROL 23 tance.3 With a total of US$3,000-in marked contrast to BAT's annual advertising budget of US$3.3 million-the groups moved forward with their strategy. From September to November 1999, BATA members conducted a series of activities, with different organizations taking the lead for different events. The president of the WBB, Saifuddin Ahmed, flew to Chittagong and looked through the docking permits for the Voyage campaign. He dis- covered that the yacht had not obtained proper permission, having applied to dock on a visit rather than for commercial purposes. BATA members designed and posted in cities all over the country "Sinking Boat" posters comparing the Voyage to the British colonization of Bangladesh. They also organized a bicycle rally from Dhaka to Chittagong, human chains in Dhaka and Chittagong, a press conference, and other events. Tania Amir of LSTB, barrister Omar Sadat of ADHUNIK, and several other individuals involved in BATA filed a petition with the High Court seeking a stop to the promotional activities planned on the yacht's arrival. BATA members made their voices heard, and their message was clear: the Voyage was not about adventure, glamour, or sophistication but about the efforts of a rich transna- tional company to hook poor Bangladeshis on expensive cigarettes. TIhe boat docked in Chittagong on November 21, 1999, one day after its expected arrival date. The mayor of Chittagong attended an event to greet the yacht, declaring that while cigarettes are dangerous to health, he wel- comed foreign investment in Bangladesh. Almost simultaneously, the High Court issued its decision: a stay order on all promotional activities of the yacht. The concerts and other events were canceled, tickets were refunded, and a small notice was published in the paper explaining the occurrence. The yacht sailed away quietly a few days later. When the case was reheard a few months later, the lawyer for BAT- one of the highest-ranking people in the opposition party-defended the Voyage as being not an advertisement for cigarettes but merely a generic promotion. His statement was challenged by barristers Omar Sadat and Tania Amir, who argued that the defense was absurd and pointed out the dangers of tobacco and the need for strong controls. With no laws to back up the argument against advertising (a law banning advertisements had been blocked in Parliament years before), Amir utilized the constitutional guarantee of right to life to support the case, arguing that the promotion of a product that causes serious disease and death is not consistent with the government's mandate to support health and life. 3. PATH Canada (the acronym stands for Programme for Appropriate Technology in Health) is an NGO based in Ottawa. 24 DEBRA EiROYMSON AND SAIFUDDIN AHMED The judge agreed with the argurments of Sadat and Amir and issued a decision that urged the respondents, including the government, to: •Ban production of tobacco leaf in phases, give subsidies to tobacco farmers to produce other agricullurai. products, and help tobacco workers find other jobs through sL ch rreans as providing vocational training * Restrict permission and Licenses for establishing tobacco factories and direct the owners to switch to other products in phases, compensating them if necessary * Persuade owners of tobacco factories rLot tc continue with produc- tion of tobacco products beyond a reasonab]e time by banning such production * Close down the bidi factories in phases and -estrict the harvesting of tobacco to produce bidis * Discontinue advertising of tobacco prod ucts and forbid any show or program that propagates smoking beyond the period of the existing contract or agreement * Prohibit import of tobacco "within a reasonable period" and in the meantime impose a heavy import tax; requi re all imports to print a statutory warning legibly in bold type in Bengali * Ban any promotional ventures such as the Voyage of Discovery * Ban smoking in public places.4 The High Court had made an asto-iishingly strong ruling in favor of tobacco control, and BATA had been born out of the ashes of the Voyage campaign (Efroymson 2000a). Power in Numbers: The Importauce of BATA Despite the victory in the f-[igh Court, the Voyage has not, in fact, disap- peared from Bangladesh. Billboards st-ill display the yacht, with the slo- gan changed to say "Followv the World Adventure." But more than just the billboards serve as a reminder of the yacht's eventful visit to Bangladesh. BATA, the alliance that was formcd lo fight ag-ainst the Voyage, is the legacy and continues in its efforts to cchieve belter tobacco control poli- cies for Bangladesh. 4. Bangladesh High Court Division Hearing on Writ Petiton No. 182 'of 1999 and Writ Peti- tion No. 4521 of 1999 in the Matter of an Application under Articlc 102 of the Constitution of the People's Republic of Bangladesh; summary available on the BATA Website, . BUILDINC, MOMENTUM FOR TOBACCO CONTROL 25 A key aspect of Bangladesh's new approach to tobacco control has been to widen the debate beyond health and enlist advocates from fields other than medicine (Efroymson 2000b). Although doctors around the world have achieved important successes in tobacco control, the exclusion of other groups has limited the effectiveness of advocacy efforts. People from fields such as law, consumer rights, and development work can bring dif- ferent perspectives to the debate and additional tools to the advocacy movement, along with, potentially, a keener focus on law and policy. Tobacco-related diseases are not considered a health priority in Bangladesh, and to focus exclusively on them would have essentially guaranteed failure in bringing about any major changes in tobacco control laws and policies. Rather than attempt to quantify the disease and death caused by tobacco, BATA focused instead on an issue of much more immediate relevance: malnutrition. As mentioned earlier, the poor of Bangladesh-as in many other countries-are much more likely to smoke than the wealthy, and the money they spend on tobacco, if used instead to purchase food, could make a significant difference in their children's nutritional status. BATA now has 270 diverse organizations around the country in its net- work, as well as an international advisory board. In addition to MANAS and the National Non-Smokers' Forum, the following organizations are members: * Body Against Destructive Social Activities, Bangladesh (BADSA). An antidrug organization, founded in 1994, that regularly organizes rallies and other events to highlight the problem of tobacco use in Bangladesh. * Consumners' Association of Banigladesh (CAB). As part of its mandate to protect consumers, addresses the issue of tobacco as the most danger- ous of all consumer products. * Dhaka Ahsaniia Missioni. Works in many sectors and has conducted many activities in tobacco control, including organizing (jointly with the LSTB) a discussion meeting on tobacco control law; persuading the Bangladesh Postal Department to produce a stamp and other materials celebrating World No Tobacco Day; organizing discussion meetings throughout the country; running a program to establish smoke-free schools; and printing and distributing stickers and posters. * Ghas Phul Nodi. An antidrug organization; conducts various activities to draw attention to the problems of tobacco use. * Institute of Allergy and Cliizical Imniun0ology, Bangladesh (IACIB). One of BATA's newest members; recently carried out a survey of ricksha pullers and their tobacco use habits and is conducting awareness programs. 26 DEBRA EFRCYMSON AND SAIFUDDIN AHMED * Law and Society Trust, Bangladesh (LSTB). A key party in obtaining the High Court decision against BAT. Tania Arnir of the LSTB has been active in the Intergovernmental NVegotiating Bocly (INB) meetings for the Framework Convention on Tobacco Control ('ZCTC) and in revising legislation for submission to the government. She is a member of the law-drafting comnmittee of the Ministry of H ealth. * MANOBIK (Madok Drabya-O-Nesha Birodi Council [Antidrug Council]). An antidrug association that has recent.Ly taken on tobacco control as a major issue. Its activities include a sit-in protest in front of the National Press Club in favor of higher taxes on tobacco products and organiza- tion of rallies and discussion meetings. * Pratyasha. An antidrug organization that conducts awareness cam- paigns on tobacco. * Welfare Associationfor Cancer Care (WACC). Currently focuses on involv- ing more organizations in addressing women's and children's issues with respect to tobacco control. It has produced various materials addressing women's tobacco use, as well as a book on tobacco and can- cer that highlights the human Face of tobacco-related illness. * Work for a Better Bangladesh (WIVBB). The WBB, as BATA's secretariat, plays a key role in coordinating BATA events. It ILas conducted a series of tobacco control training workshops throughout the country. It coproduced, with PATH Canada, the "]Hlungry for Tobacco" report and two PATH Canada publications: a how-to guide for tobacco control and a guide to tobacco control law. The WBB has issued and is distrib- uting, through BATA, a booklet of advice on quitting smoking, and it has produced various leaflets, stickers, and posters. Saifuddin Ahmed, WBB president and coordinator for BATA, has ati ended INB meetings, is active in the Framework Convention Allance (a coalition of NGOs working for a strong FCTC), and sits on the law-drafting committee of the Ministry of Health. * Young Power in Social Action (YPSA). Based in Chi tagong; had a critical role in organizing events to protest the landing of the Voyage of Dis- covery yacht in Chittagong port. With the WBB, it also organized a workshop in Chittagong, and it is activ\e in encouraging local organi- zations to work on tobacco corLtrol. The BATA member organizations listed hern are NGOs registered with the govermment of Bangladesh. Witia the exception of the YPSA, all are based in Dhaka. Most are small organizations -with a flexible structure that facilitates their involvement in the politically sensitive area of advocacy. BATA's mission is to: * Contribute to the health and well-being of Bangladeshis by reducing tobacco consumption BUILDING MOMENTUM FOR TOBACCO CONTROL 27 * Reduce the damage to health, the environment, households, and the national economy from tobacco consumption * Educate the public and policymakers about the dangers of tobacco * Help strengthen the nation's tobacco control policies and legislation * Conduct research to learn more about tobacco use and its effects, par- ticularly its economic impact * Raise awareness among development organizations about the impor- tance of tobacco control and encourage more groups to become involved * Continue to be a strong, united force in tobacco control locally, nation- ally, and internationally. The alliance has been active since its inception in leading and coordi- nating activities pertaining to education, awareness raising, training, advocacy, research, and coorcLination with government and NGOs on both the national and the international levels. These activities are an example of how NGOs can influence policy and build coalitions, as long as the members are willing to suspend an interest in exercising control and assuming leadership in order to work cooperatively. The following are just some examples of activities that BATA has championed since its founding in 1999: * Advocacy. BATA has regularly held events calling for legislative changes, including a signature campaign in favor of nonsmoking car- riages on trains and protests calling for higher tobacco taxes and an end to tobacco advertising. BATA is also urging the government to negoti- ate for and sign a strong Framework Convention on Tobacco Control. * Draft legislation. After compiling laws from various countries, BATA helped draft a comprehensive tobacco control law which, as of March 2003, was still being discussed in parliamentary committees and is yet to be voted on by Parliament. The draft law bans advertising (except at point of sale), mandates pictorial warnings on cigarette packs, and prohibits smoking in many public places. BATA is working to strengthen the provisions and to ensure that the law is not weakened by Parliament. * Public education. BATA members produce a range of materials, includ- ing posters, stickers, and pamphlets, to educate the public about the dangers to health, economics, and appearance from tobacco use and about how to quit smoking. * Public mobilization. BATA encourages the public to take a stand against tobacco promotion and use. Mobilization activities include rallies and marches for the WHO's South-East Asian Anti-Tobacco (SEAAT) Flame for Freedom from Tobacco campaign in which, in 2000, a torch sym- bolizing the tobacco control movement traveled throughout South and 28 DEBRA EFROYMSON AND SAIFUDDIN AHMED Southeast Asia. BATA has also held workshops, seminars, and press conferences on tobacco control themes. • Research. BATA has conducted studies on the effect of tobacco use on poverty and has carried out research cn demand for a smoke-free bus service. It has also run an analysis of BAT's "Youtlh Smoking Prevention Campaign," which included use of focus groups and a questionnaire. * International activities. BATA has atternded and made presentations at various international workshops and conferences, including regional meetings in India and Thailand, the People's Health Assembly, various WHO meetings, and the 11th World Conference on Tobacco or Health. Fifteen of its member organizations have made submissions to the WHO expressing support for a strong FCTC, and BATA is an active participant in the Framework Convention Alliance. By broadening the base of support for tobacco control, BATA hopes to build a much stronger movement For tobacco control advocacy. With that in mind, the WBB, with financial su3port from the Amrerican Cancer Society and technical support from PATH Canada, is hclding a series of workshops around the country for NGOs and the meclia on tobacco control. The work- shops emphasize that tobacco is a multisectoral issue, one that touches on the environment, poverty, human rights, religion, and many other areas, as well as health. In the workshops the participants, mostly from small local NGOs, engage in small-group discussions to plan activities and create work plans. The WBB hopes in the future to provide small grants for these NGOs to encourage them to put some of their ideas into practice. Tobacco control policy cannot be successfully iormulated or imple- mented unless a broad base of NGOs arouncd the zountry actively sup- ports it. Effective support for a lnrge NGO network is in turn contingent upon raising awareness among NCOs about the importance of tobacco control and their capacity to become effective advozates. In BATA's case, technical and financial support From Arnerican and Canadian agencies has been essential in enhancing the capacity of local NGOs to support the government and promote good policies for tobacco control. The Politics of Policynmaking Bangladesh's democracy does not always operate smoothly. Rather than discussing issues in Parliament, the opposition party sometimes stages walkouts and then protests if deciiio as are made in members' absence. The most common form of protest is a hartal (general strike), in which a party or a coalition of parties asks people to stay home, usually from dawn to dusk. Reported cases of corruption and bribery within the government BuILDING MOMENTUIM FOR TOBACCO CONTROL 29 system further undermine the democratic process. These characteristics, coupled with the influence that tobacco companies wield, make tobacco control efforts difficult. Despite all the vagaries of Bangladeshi politics, the government holds most of the solutions to the problem of tobacco use. Without strong laws and high tobacco taxes, there is little that organizations and individuals can do. This should not be used as an excuse to accept defeat; rather, it should be a reminder to everyone working in the field of tobacco control of the importance of continuing advocacy work. Bangladesh's existing laws on tobacco control are weak. Advertising is banned on state-controlled media (BTV and radio) but is allowed every- where else, including on local private and satellite television stations, in newspapers and magazines, and on billboards. Sponsorship of rock con- certs by BAT (e.g., Benson & Hedges Star Search) is common, and despite the claim that youths under 18 are not admitted, no such rules appear to be followed (WBB and PATH Canada 2001). In addition, airing the pro- grams on television effectively guarantees a young audience. One national daily newspaper, Bhorer Kagoj, voluntarily refuses to run tobacco advertisements (Simpson 1998), but other newspapers frequently run half-page, full-color advertisements for cigarettes. Billboards, storefront signs, cigarette display cases, and other forms of advertising are wide- spread throughout the country. Smoking is banned in hospitals and some other premises, but these prohibitions are largely ignored. Operators of many air-conditioned buses and some owners of air-conditioned restaurants voluntarily forbid smok- ing. Biman, the national airline, prohibited smoking on domestic flights years ago, and in April 2001 it extended the ban to all international flights. Warnings on tobacco products are limited to cigarette packs and con- sist of one weak statement, in Bengali and in small type, on the side of the pack. None of the other tobacco products available on the market are required to carry a warning. The government is currently in the lengthy process of revising its tobacco control laws and drafting new ones. Pressure to do so came largely from the High Court's decision following the Voyage of Discovery case. If the new draft law under consideration is passed in its present form, it will be an enormous improvement and will provide a strong leg- islative base for better tobacco control in Bangladesh. Advocates continue to work to convince policymakers of the need for a comprehensive ban on promotions, strong and clearly visible warnings on all tobacco products, and protection of nonsmokers, among other measures. BATA has developed a close working relationship with the government on the basis of simple principles appropriate to the Bangladeshi cultural 30 DEBRA EFRO)\MSON AND SAIFUDDIN AHMED environment, such as working v itli the governmert, rather than against it, and providing assistance to the goverrnmcnt in carrying out its pro- grams where possible. BATA members generally r gard confrontational tactics as counterproductive in dealing with the government. In their view, the key to success in Bangladesh lies in main:aining a strong, close working relationship with the gcvernment and thus being able to form a constructive relationship with policymakers-an essential ingredient of effective tobacco control policies. S-ach a rela,:ionship does not preclude criticizing government policies or advocatting strongly for change; rather, it involves a constructive attitude toward working with policymakers, based on mutual respect. BATA tries to focus on providing services to the government-for example, designing stickers and posters and helping to organize govern- ment events. Where necessary, this includes providing services gratis and without taking credit. In return, Ihe government is open to collaboration. Although this process means extra work for tobacco advocates, the pay- off can be significant in developing and maintaining, a strong relationship with the government. Some of the ways in which BATA has sought to provide support for the government include: * Organizing activitLes for WlH[O's Flanne for Freedom from Tobacco campaign. * Designing posters and organizing rallies for World No Tobacco Day. * Briefing the gover-nment on the Framework Convention on Tobacco Control. This gave delegates the informationi the) needed to participate in meetings and allowed BATA to present iLs view of the proposed lan- guage for the FCTC during the governmen t negotiations. The relationship between BATA ancl the governiment has been close and successful enough that BATA received the WHO's Tobacco Free World Award in 2001 at the recornme.idation oi the government. In addition, two members of BATA-Tania Arrir of :he LSTB and Saifud- din Ahmed of the WBB-have been invited to sit on the Health Min- istry's law-drafting committee and to participate directly in the process of drafting new legislation. In some respects BATA members now serve as a liaison between other BATA organizations and the government, soliciting ideas from members on what should go into the laws and what language should be used. The battLe wi 11 not end with the passage of new laws: BATA members will a]so have a critical role to play in mon- itoring the behavior of the tobacco companies and ensuring enforcement of the laws. BUILDING MOMENTUM FOR TOBACCO CONTROL 31 Lessons Learned Despite the progress that has been made, challenges remain. Among them are funding, the struggle to build the political will necessary for change and to establish tobacco control as a priority for the country, the con- struction of lasting alliances, and the continuing strength of the opposi- tion. But important lessons have been leamed in each of these areas. Obtaining Funds Important work such as advocacy for new laws can be done even with lim- ited funding. Some of the strongest laws in other countries were passed when tobacco control movements had relatively little funding, as in South Africa and Thailand. But although ample funding does not guarantee suc- cess, it is difficult to do the work with no funding; critical tasks such as law enforcement and surveillance of the epidemic to measure progress can be expensive. Certain assets that are taken for granted in developed countries- a steady power supply, phone lines, computers, e-mail and Web access, and a good command of English-are in short supply in many developing coun- tries. Such comparatively simple matters as finding basic information to back up a proposal for new laws, a space in which to hold meetings, and the money to print documents can be major obstacles. Lack of full-time staff devoted to tobacco control-and with access to resources-can seriously undermine efforts. From the perspective of tobacco control advocates, the ideal source of funding is a dedicated tax on tobacco, but advocacy groups need immediate funding to sustain the (perhaps lengthy) lobbying effort needed to get such a tax passed. Large organizations that have sufficient funds to conduct the work may shy away from advocacy, preferring less controversial areas such as school-based programs. One way of overcoming lack of funds is through partnerships with local NGOs or with institutions in developed countries. To help provide at least minimal operating funds, PATH Canada offered the WBB some startup funding, shared office space, and, perhaps more important, ongoing tech- nical input. PATH Canada's support enabled the WBB to focus on tobacco control work, including the building of BATA, rather than on seeking funds. The relationship also gave the WBB the assurance that small, neces- sary expenses could be met, such as those involved in holding a press con- ference and establishing computer and e-mail links for global networking. The technical assistance has been valuable in gathering evidence to support arguments for tobacco control. It enabled the WBB to provide the essential foundation and minimum operating costs for BATA, with other organiza- tions contributing some funds and large amounts of time and expertise. 32 DEI3RA IFRO"\\4SO\T ANI) SAIFUDDIN AHMED Having created an excellent tr-ack ecord in ii:s first year of work, BATA was able to gain supplementary fundling in the following forms: * Three small one-year grants From he American Cancer Society to three BATA member organizations--the LSTB, t:o) support legal advocacy; the Welfare Association for Cancer Care, to work on issues affecting women and children; and the W\TBB, to strengther BATA through divi- sional workshops and printed materials * A two-year grant from the Canadi,n International Development Agency (CIDA) to PATH Canada, the WBB, and t3ATA to develop and print materials, hold workshops, develop the capacity of WBB and BATA staff, and desigin and air counteradvertising. In addition to these specific grants, 13ATA mernbers have received funding from the WHO, the Rockefeller Foundation, the Canadian Can- cer Society, and other groups to attend workshops, rneetings, and confer- ences. Because dependence on external Funding is a concern, BATA is seeking to increase contributions frcm its member organizations and to finance some of its publications by accepting advertLsing. Much work can be done with little money if resources are used wisely. Writing letters, holding meetings, organizing public demonstrations, and talking to politicians cost little. Rather than waiting ior funds to material- ize, it is best to make a start, utilizing existing resources. If the work is suc- cessful, it will be easier to find funding in th-ie iuture. Creating Political Will and Workinmg wuifth the Media It is often said that polcy change cannot occur withcut political will. This statement seems to imply that political xvill i, sorrLething innate rather than created-a dangerously passive approach to advocacy. Although that may sometimes be the case, a critical part of tobacco control is to cre- ate the will to make the changes. Arid in a dc -iocraitic government, this often means convincing politicians that they v, ill gain more votes if they are seen to support tobacco control. How does one go about generating political will? * Educate and inivolve the ptiblic. A public Lnawv\are of the problems associ- ated with tobacco use and of the role the tobacco industry plays in blocking legislation will not pu t pressur-e on politicians for change. The public needs to know not only that tobacco is harmful but also what role the tobacco industry plays in opposing policies designed to reduce tobacco use. Involving the public includes taking the lead in activities such as letter-writing campaign s, petition-s, and public demonstrations. BUILDING MOMENTUM FOR TOBACCO CONTROL 33 * Educate politicians. Politicians need to know how the tobacco industry may be trying to manipulate them through public relations activities and lobbying (e.g., suggesting that taxes be lowered to reduce smug- gling when in fact the tobacco company itself has been shown to be involved in smuggling in several court cases). They need to understand the implications of tobacco use on health and the economy. And they need to know that activists will not keep quiet. Well-intentioned but ill- informed politicians can be educated to support tobacco control, and others can be shamed into doing so. * Show politicians that there is strong public demandfor tobacco control. Cre- ating visible support for the issue-through public demonstrations, editorials, letters to the editor, and so on-can help persuade politi- cians that they will gain more by doing as the public wants than by pleasing their friends in the industry. The media are critical to the creation of political will. Given the low budgets of most tobacco control programs around the world, the use of free media coverage is essential. One of the successes of tobacco control work in Bangladesh has been the ability to gain media attention. Activi- ties have included: * Holding press conferences. * Inviting the media to seminars and workshops. * Organizing rallies, human chains, and other protests, often in front of the National Press Club. * Writing letters to the editor. * Holding discussions with the newspaper Bhorer Kagoj that led to the publication of color messages about tobacco every day during the month of May, free of charge. * Maintaining positive relations with the press. For instance, the Eco- nomic Times, a weekly newspaper on economic issues, frequently car- ries news releases provided by BATA. It is possible that the willingness of the media to report on tobacco con- trol topics, including the dangers of tobacco use, is in inverse proportion to the amount of income they gain from tobacco advertisements, although no study on this has been done in Bangladesh. The authors' subjective observation is that newspapers such as Bhorer Kagoj, with no tobacco advertisements, and The Observer, with only sporadic ones, devote more attention to tobacco-related problems than do newspapers that regularly run tobacco advertisements. The media in many countries gain significant income from tobacco advertising, but there are always some individuals and institutions that 34 DEBRA EFROYMSC4N AND SAIFUDDIN AHMED are willing to help prevent disease and death from tobacco use, that envi- sion a more effective role for the government in tobacco control, and that are prepared to provide support gratis. Building relationships with the press often pays off in free media coverage. We do not know what is pos- sible until we try. Competing Priorities In many low-income countries there is a general feeling that tobacco con- trol is an issue for rich countries that have the "luxury" of being able to worry about chronic diseases, while low-income countries have to con- centrate on infectious disease, malnutriticon, access to clean water, and the like. Framing the tobacco problem onlly in terms of cancer, or even only in terms of health, adds to this perception. Talking about the number of deaths likely to result from tobacco use can be inefFective, as many such deaths are likely to occur late in life. Where life expectancy is low, mor- tality from cancer and heart disease is noi: likely to be considered a prior- ity, no matter how significant it may in fact be. While never forgetting that tobacco is primarily a health issue, tobacco control advocates in Bangladesh have tried to stress that the health prob- lems arise not only from disease but aLso from the opportunity costs involved in spending money on an adcLictive and harmful substance rather than on food or other basic needs. The argurent is most appropri- ate when applied to tran,snational tobacco companies whose products are essentially unaffordable for most of the population yet are so widely advertised that they are likely to become aspi rational goods, even at the cost of a large portion of family income. Repositioning tobacco use as an issue of poverty, nutrition, and human rights can gain tLhe attention and support needed to deal with an entirely preventable epidemic. It is important to be innovative in framing tlhe tobacco control issue and to use concepts appropriate to the setting. In some areas the focus might best be on the environmental damage resulting from tobacco cultivation and curing; in others, on the labor issues involved in tobacco production. Tobacco control advocates shoulcd be flexible enough to present the issue in a way that broadens support and to obtain or develop the knowledge base on which to build their efforts and claims. Maintaining- a Strong Alliance Alliances can be powerful tools, but they are oEten fraught with problems. It can be difficult to maintain a balance between attending to the organi- zational and relationship issues that have to be addressed to keep the alliance functioning and staying focused on the actual work of tobacco BUILDING MOMENTUM FOR TOBACCO CONTROL 35 control. Bangladesh has experienced mixed success in this area: although BATA is strong and continues to grow, it has not been able to maintain the involvement of all the key players. Working within a coalition has many advantages: * The coalition can draw on the strengths of individual members, giving it access to a base of skills, experience, and connections that would be hard to find in any single organization. * A coalition increases the number of voices speaking out and thus the level of attention to the issue. * A coalition can be a forum for sharing ideas and communicating about individual actions so that even when joint organizing does not occur, work is more coordinated and groups do not unnecessarily duplicate each other's efforts. * A coalition can, when it functions well, be an energizing force, where individual members gain ideas and motivation from each other and all face the work with greater eagerness. But maintaining a strong and active coalition is difficult. Challenges can arise if individuals focus on personal gains and prestige more than on group plans or institutional objectives, if there is conflict over the best approach to shared work, and if personal conflicts or animosity arise. In such cases, creating smaller working groups or committees may be the way to continue building the group's effectiveness. In Bangladesh the formation of an alliance was critical to the successes achieved. A balance is always needed between the administrative, orga- nizational, and personal tasks needed to keep individual members satis- fied and a focus on the work at hand. There is no such thing as a "perfect" coalition, but if the group can achieve more than was previously possible, without impossibly high inputs of time and other resources, then it can be described as successful. While the building of an alliance or coalition is one way to increase effectiveness in tobacco control, by no means should it come at an excessive cost in money, time, or energy. Standing Up to the Opposition The task of tobacco control often-and understandably-appears daunt- ing. What can a few individuals or organizations working in the interest of public health do when faced with the power of one or several transna- tional tobacco companies, with their enormous financial resources and political connections? At least David and Goliath were standing on the same field; the tobacco industry may have access to lawmakers and other officials that tobacco control advocates can only guess at and wish for. 36 DEBRA EFROY\450N AV\) SAIFUDDIN AHMED It is unrealistic to expect that the task will be simple. There will always be times of discouragemeni. [t is imPortant to keep a sense of perspective and to remember th-at even in the countries that boast the greatest successes in tobacco control, abouit a quarl:er of the population still smokes; in many o:her countries, the percentage is far higher and continues to rise. Every time a tobacco company lEunches a new public relations cam- paign, or a government cuts tobacco taxes or refuses to pass new legisla- tion or passes legislation drafted by the tobacco industry itself, there is a need for advocates to take stock. Yes, the tobacco irLdustry is a powerful adversary, and yes, the companies have vast financial resources, but they are also trading in a deadly and add ctive proc,uct that most of the popu- lation does not consune and that most addicted users wish they could stop using. The victories achieved by tobacco ccntrol advocates and policymakers are almost always hard-fought. There are plenty of setbacks along the way, and a long way farther to go, but however great the power of might, even greater is the power of right. A powerful opponent can sometimes provide motivation. BATA was formed during the struggle against BAT ove, the Voyage of Discovery, and other work was inspired by BAT's launch of its "Youth Smoking Pre- vention Campaign." Policymakers and advocates, wiorking together, will be able to curb BAT's ability to advertise, thus narrowing the gap between the tobacco industry's reach and BATA's. The only iure path to defeat is to accept it without a struggle. Conc usiciCI Most of the story of tobacco control in Bangladesh is still unwritten, and events continue to unfold. It remains to be seen whether the tobacco con- trol movement will be sufficien.ly powerful and proactive to counter industry tactics and persuade the government to take strong measures to control tobacco. The tobacco industry is a migl-ty fcrce in Bangladesh, as elsewhere, and it will be difficult o rnaintain a spotlight on tobacco in the face of so many competing causes of disease and ill health. But if the progress made over the past few years is any indication of the future, the many organizations and individuals wAorking for tobacco control in Bangladesh have good reason to lie optimnstic Re feiences ADHUNIK (Amra Dhumpan Nibaron Kori). 1988. "Prioceedings of the First National Seminar on Tobacco and Smoking, 1988, Dhaka, Bangladesh." Dhaka. BUILDING MOMENTUM FOR TOBACCO CONTROL 37 Ahmad, M. 1995. "Tobacco and the Economy of Bangladesh." Keynote speech deliv- ered on World No Tobacco Day, May 1995. Bangladesh Cancer Society, Dhaka. Bangladesh Bureau of Statistics. 1996. Prevalen?ce of Sinoking in Bangladeslh. Dhaka. . 1998a. Household Expenditlure Survey 1995-96. Dhaka. . 1998b. Foreign Trade Statistics of Bangladesh 1997-1998. Dhaka. .1999. Statistical Poclcetbook Bangladesh 1998. Dhaka. BAT (British American Tobacco). 1998. "Reports & Accounts 1998." Dhaka. . 2000. "Code of Conduct." Dhaka. BATA (Bangladesh Anti-Tobacco Alliance). 2001. Mukhlapotr-o Nezosletter, April-June (in Bengali). Dhaka. Corrao, M. A., G. E. Guindon, N. Sharma, and D. F. Shookoohi, eds. 2000. "Tobacco Control Country Profiles." American Cancer Society, Atlanta, Ga. Efroymson, D. 2000a. "Bangladesh: Voyage of Disdain Sunk without Trace." Tobacco Control 9 (2): 130-31. Available at . . 2000b. "BATA Battles BAT in Bangladesh." Global Health & Environ1ment Monitor 8 (2). Efroymson, D., S. Ahmed, J. Townsend, S. Alam, A. Dey, R. Shah, B. Dhar, A. Sujon, K. Ahmed, and 0. Rahman. 2001. "Hungry for Tobacco: An Analysis of the Economic Impact of Tobacco Consumption on the Poor in Bangladesh." Tobacco Control 10 (3): 212-17. Available at . Haq, N. 2001. Oral presentation at Tobacco Control Workshop, April 2001, Chit- tagong, Bangladesh. Work for a Better Bangladesh, Dhaka. Shaha, R., B. Dhar, and D. Efroymson. 2000. "Satellite Television Advertising in Bangladesh." Presentation at the 11th World Conference on Tobacco or Health, 2000, Chicago, Ill. Simpson, D. 1998. "Bangladesh: Not a Cigarette Paper." Tobacco Control 7 (3): 228-29. Available at . UNICEF (United Nations Children's Fund). 1998. The State of the World's Chil- dren 1998. New York: Oxford University Press. .2000. "Child Work in the Bidi Industry." Dhaka. WBB (Work for a Better Bangladesh) and PATH Canada. 2001. "BAT's Youth Smoking Prevention Program: What Are the Actual Goals?" Dhaka. WHO (World Health Organization). 1997. Tobacco or Health: A Global Status Report. Geneva. World Bank. 1999. Cuirbing the Epidemitic: Governments and the Econiomiiics of Tobacco Control. Development in Practice series. Washington, D.C. 3 Government [Leadership in Tobacco Control: Brazil's Experience LiLUsa M. da Costa e SiJva GCldfarb Abroad national network of decLicated activists helped achieve Brazil's suc- cess in tobacco control. Thousands of comrnilted individuals have worked together and have enlisted the support of pol iticians, religious leaders, and the media to increase public avw areness of the hazards of tobacco use and limit the influence of the tobacco industry. Their vol untary and professional efforts have made Brazil a world leader in tobacco control. This case study describes tihe creation and consolidation of Brazil's National Tobacco Control Program (NTCP) at the National Cancer Insti- tute (INCA). It emphasizes the strategic decisions that led to new laws, higher taxes, and educational programs. The Scope of the Tobacco Problem in Brazil Tobacco consumption in Brazil-as in other couniries in Latin America- grew throughout the 1970s and 1980s, fueled by A significant increase in the proportion of females smoking (l'AHO 1992; USDHHS 1992). By 1989, 30 percent of the population over the age of 15 smoked. Of Brazil's 30.6 million smokers, 18 million (59 percen.) were male and 12.6 million (41 percent) were female (Ministry of Health and IBGE 1989). In 1989, 2.742 mnillion Bra2ilizn children ancl adolescents age 5-19 smoked. Of these, 369,767 were between the ages of 10 and 14, and 2,341,151 were age 15-19. Among children younger than 10 years old, there were 30,531 smokers, 98 percent of them in ru-ral areas (Ministry of Health and IBGE 1989). Surveys in 10 Brazilian state capital cities in 1987, 1989, 1993, and 1997 showed an increase in the percentage of school attenders age 10-18 using tobacco for the first time (Ga dur6z, Ncto, and Carlini 1997: 130). The same studies showed that first Lise o tobacco among girls increased between 1987 and 1997. By the 1997 survey, in 3 of the 10 state capitals studied-Porto Alegre, Rio de Janeiro, and Sao Paulo-first-use 38 GOVERNMENT LEADERSHIP IN TOBACCO CONTROL 39 numbers for the 10-18 age group were higher for girls than for boys. In Curitiba, Salvador, and Recife there was no statistically significant differ- ence between boys and girls in age of first use. The study concluded that the percentages of male and female smokers would soon be equal. The data on young Brazilian smokers, in particular, raised the alarm. Studies have shown that 50 percent of those who try cigarettes for the first time as adolescents become adult smokers (Henningfield, Cohen, and Slade 1991; USDHHS 1994; WHO 1998). The data highlighted the urgent need for measures to reduce the number of young people who experiment with smoking. Health and Environmental Effects of Tobacco Use and Produiction An estimated 80,000 people die every year in Brazil from the effects of tobacco use (Silva and others 1998b: 71). Cardiovascular diseases are by far the biggest cause of death, accounting for 27.5 percent of all deaths, and cancers are in fourth place; both are strongly related to tobacco use (Ministry of Health 1999a; Duchiade 1995). Added to the gloomy health data for smoking is the impact of tobacco production on people and the environment. Tobacco crops are grown with intensive use of chemicals: soil sterilizers, fertilizers, and pesticides that can all be highly toxic (Perez 1990). This means that both people and the environment-soil, water, air, and animals-have been systematically contaminated by chemicals for years. Brazil also suffers other negative effects of growing tobacco. The use of wood to feed 116,000 ovens to cure tobacco leaves has contributed to the loss of native forests in southern Brazil, which are now only 2 percent of their original extent (Quesada and others 1989; Lopes and others 1992). Brazil's Tobacco Economy Brazil is the biggest tobacco exporter and the third largest tobacco pro- ducer in the world. In 2000 it produced 595,000 metric tons of tobacco leaves and exported 341,000 tons, which brought in US$961.2 million in revenues (MDIC/SECEX 2001). The size of the tobacco industry in Brazil can also be measured by the 165,000 families (about 700,000 people) who make their living from growing tobacco and the 1.3 million more whose income indirectly derives from the tobacco industry (ABIFUMO 2000). Taking measures that could affect this economy requires considerable care. Changing the tobacco economy may not be as difficult as it seems, however, because the Brazilian economy does not depend on tobacco production. Only 2.6 percent of all export earnings comes from tobacco. (By contrast, in Zimbabwe the percentage is 23 percent and in Malawi, 40 I.uISAN M. )A COSTA F SILVA GOLDFARB 61 percent-W/Vorld Bank 1999: 'L22.) Or course every job is important, but tobacco farmers represent only 0.44 of I percent of all full-time jobs in Brazil, and even if indirect employment is added the tobacco industry's contribution to employment is srralt. Furthermore, if people stop smok- ing, they spe-nd the money on other goods and services instead, and this generates new jobs across the economy. As a tobacco exporter, Brazil I must prepare for global changes in con- sumption. Tobacco controls are growing str;nger around the world, and the industry is shifting its sources of supply. This could well lead to a drop in demand for Brazil's tobacco, and su]pply must adjust. The sooner that a tobacco-exporting economy such as Brazil be;ins to redirect invest- ments away from tobacco, the quicker and better it will be able to adjust to future global consumption and trade patterns. Given the environmental damage and health risks from tobacco, 41 percent of tobacco producers surveved .n southern Brazil said they would switch from tobacco to another crop if certain economic conditions existed, including the availability of good credit and a guarantee of a mar- ket for the new crop (Eltges 1989). The results of this survey were rein- forced at a meeting in 2001 of farrrmers, government officials, workers, and institutions interested in the fate of the tobacco economy. Farmers empha- sized that they would need financial help to switch to alternative crops (Ministry of Health and others 2001). Governmenit Slupportfor Tobacco Farmers are only one part of the tobacco economy. Firms involved in man- ufacturing and selling tobacco products make up another powerful group. Vigorous lobbying by this industry has produced a level of government support out of proportion to the commodity's economic importance. Data show that since 1997, 22 percent of all resources from the National Pro- gram for Family-Run Agricultural Businesses (PRONAF) has been used for tobacco crops, particularly in the south, where 93 percent of tobacco production is concentrated (BACEN 1999; M[inistry of Health 2000a). Aim- ing to reduce this percentage, the Brazilian Centra I Bank has forbidden the use of PRONAF funds to finance tobacco production in partnership with or through "integration" with the tobacco industry (Resolution 002833, April 25,2001). Individual tobacco growers are still eligible for these funds, but they lose their eligibility if the tobacco induslry acts as an intermedi- ary for them or if they have any di -ect association with tobacco companies. The Beginnings of lobacco Control in Brazil As long ago as the early 1970s, some BraziLians were worried about the harmful effects of tobacco. Bult actions to control its use were limited by GOVERNMENT LEADERSHIP IN TOBACCO CONTROL 41 pressure from the industry and by lack of knowledge among health pro- fessionals, politicians, and the general public. The first attempts at tobacco control took place in several different areas: Bahia, Parana, Espirito Santo, Rio Grande do Sul, Sao Paulo, and Rio de Janeiro. The main players, and the driving force behind these attempts, were health professionals-mostly physicians-motivated by information from international publications. Some of the original tobacco control advocates are still active. Dr. J. Rosemberg of Sorocaba Medical School deserves special mention because of his inspiring example. At the age of 93, he is the president of the Coordinating Committee for Tobacco Control in Brazil (CCCTB) and is still speaking up about tobacco. In 1977 the National Cancer Association drew up an action plan to con- trol tobacco use. The following year, as a spinoff of the plan, the associa- tion organized Anti-Tobacco Use Week and launched Rosemberg's book Tobacco Use: A Putblic Health Issuie. Two years later, acting on a proposal by the Brazilian Cancer Society, the Brazilian Medical Association organized local committees to give talks to physicians about the effects of tobacco use. They also pressed to have the subject added to the curricula of med- ical and paramedical schools and placed on the agenda of medical con- gresses around the country. In 1979 the First Symposium on Tuberculosis took place in Salvador, Bahia state. The resulting "Salvador Letter" contained information and warnings about the harmful health effects of tobacco use (Rosemberg 1987). The letter also provided the first estimate of mortality related to tobacco use in Brazil: 100,000 per year. (Later, this figure was revised downward.) The letter recommended a two-pronged preventive approach to controlling tobacco use through education and legislation. In April 1980 the First Brazilian Conference against Tobacco Use was held in Vit6ria, Espirito Santo state, and produced a similar document, the "Vit6ria Letter" (Rosemberg 1987). Growing awareness of the dangers of tobacco use increased public sup- port for tobacco control activities. Politicians in some states recognized the strength of this support and added tobacco control to their political agendas. The state of Parana, for example, organized the first Strike Against Tobacco Use and established the statewide Day Against Tobacco (Law 7,419, 1980). During the strike, students collected tolls from passing motorists to raise funds for the campaign, educational handouts were distributed, and non- profit organizations provided funding to support the effort. In the early 1980s countries in the region created the Latin American Coordinating Committee for Tobacco Control (CLACCTA) through an initiative of the U.S. Centers for Disease Control and Prevention (CDC) and the American Cancer Society. CLACCTA's first president was the late Dr. Mario Rigatto, a very active professional from Rio Grande do Sul and one of the pioneers in Brazilian tobacco control. 42 LU[SA M. DA COS-TA E SILVA GOLDFARB Brazilian tobacco control efforts evolved slowly until 1985, when the federal government began participating rn the process. Health Minister Waldir Arcoverde established a commission to write a national tobacco control action plan for the ministry. The co-mmLission worked quietly for more than six months, avoiding altention from the industry and its lobby- ists. Brazil's first Action Plan for Tobacco Conttol was completed in 1986. An important element in the p]an was ;he involvement of the National Health Foundation (FUNASA) of the lMinistry o Health. FUNASA's existing national network for tuberculosis control became the distribution system for information about the harmful health effects of tobacco, with pneumologists Germano Gherardt, Jose do Val e Feitosa, and Miguel Aiub Hijjar playing key roles. In June 1986 Federal Law 7,488/86 created the National Day Against Tobacco (August 29) and reserved the week prior to the day for national events related to the issue. That law, although weak, was a great step for- ward in Brazilian tobacco control legislation. Gaining Momentum: The Nalional Tobacco Control Programrr Brazilian tobacco control efforts reached a turning point in 1987, when the National Tobacco Control Program (NTCP) was established. The head of the chronic degenerative disease unit in the Ministry of Health, Geniberto Paiva Campos, provided the needed support arid political status to launch tobacco activities under the program throug'- INCA, which desig- nated Vera Luiza da Costa e Silva as its representative on the program. Between 1987 and 1989 the group in charge of the NTCP was limited to a few professionals who worked under INCA's coordination but were based in different departments of the i\4Inistry of Health. NTCP's first strategic action was to identify health technicians i -t the state health sec- retariats to act as NTCP's state coordinators and to be responsible for delivering the program in their states. Also in 1987, the Ministry of Health established thie Advisory Board on Tobacco Use Control, and the first National Day Against Tobacco was celebrated. This was the first time that the Brazilian people were officially given information about the damage caused by tobacco and the impor- tance of reducing its use. Busi7ness Joinis I1n Businesses were involved early in tobacco control efforts. The law that created the National Day Against Tobacco appealed to businesses by insti- tuting an honors certificate awarded by the Ministries of Health and GOVERNMENT LEADERSHIP IN TOBACCO CONTROL 43 Labor to companies that attained certain standards such as workplace smoking bans, restricted smoking areas, and educational programs. The participation of business greatly benefited the program because the com- panies' actions provided examples for others to follow. In the first eight years only a few companies received certificates, but since 1996 the num- bers have grown, and the system has become a success. The Central Bank (Banco do Brasil) deserves special recognition because of its participation in the plan right from the beginning. Banco do Brasil has contributed enormously to the program. It has been a role model for other companies and institutions through its occu- pational health initiatives, including tobacco control, and its support for sports and "healthy" events such as swimming, jumping, running, danc- ing, and athletic competitions known as Largue o Cigarro Correndo (Run- ning Away from Cigarettes). In the 1990s these competitions were taken to 600 cities where the bank's Workers' Athletic Association (AABB) had branches. This increased the NTCP's visibility around the country and spread information about the harmful health effects of tobacco to the gen- eral public. Later, as a part of World No Tobacco Day, coordinated by the World Health Organization (WHO), the NTCP's coordinating body extended the honors certificate awards to individuals who supported the government's campaign against tobacco. People in the media, writers, actors, lawyers, teachers, and athletes have received certificates. The awards have attracted considerable public attention and wide media coverage-so much so that the president and the health minister are increasingly seen at these celebrations. Support Grows Public campaigns against tobacco grew in importance as people's under- standing of tobacco's harmful health effects increased. Between 1987 and 1989 a variety of activities boosted public awareness. * In 1988 Ministry of Health Act 490 required cigarette packs to display the warning "The Ministry of Health advises: smoking causes damage to health." * A survey showed that 70 percent of children questioned lived in a home where at least one person smoked (Silva 1987). This statistic was widely discussed in the media. * Some 70,000 students from 16 states took part in the antitobacco Chil- dren's Slogan and Drawing Contest. * Radio and TV campaigns on the effects of secondhand smoke were launched, with great impact on public opinion. 44 LUISA NI. DA COS-CA E SILVA GOLDFARB * A children's comic magazine, Siop Smokieg Arnntd Me, by a major Brazilian comic book artist and featuring a well-known female hero, was published. * Four posters designed by anothe - Brazilian comic book artist and tar- geted at different population g-oups were distributed around the coun- try. Tern years later, one of these posters appeared on the cover of the international journal Tobacco Control, published by the British Medical Journal Publishing Group. Efforts Stall and Then Resuinie Tobacco control efforts abruptly stalled in 1990 when the NTCP was taken from INCA and transferred to Bras lia. This shift brought the program to a halt. At that time, the author becarme part of the INCA team, which con- tinued its involvement in tobacco control at an inslitutional level. At the end of 1992 Health Minister Adib Jatene mnovcd the NTCP back to INCA. The INCA team was delighted: the minister had the political will needed to carry on the program. Vera da Costa e Silva wac once again in charge of the NTCP. In 1993 INCA restarted the program with a technical coor- dinating team that consisted of Vera da Costa e Silva, Tania M. Caval- cante, Tereza P. Feitosa, and the author. The team pushed hard to maka up for lost time. It ran its first capacity- building workshop in 73 health units in R'io de Jane ro-a first step in tak- ing the NTCP to local health units. In addition, an annual evaluation and planning meeting was held at which 14 of Brazil's 27 states were repre- sented. Much work still needed to be done to cover all the states. That same year, NTCP staff participated in the Annual Seminar on Alternative Crops organized by the Catholic Church. They debated with tobacco growers and agrotechnicians in southern Brazil, the heart of tobacco production in the country As a result of that work, today 1,000 families grow alternative crops suci- as corn and beans instead of tobacco. The NTCP was gaining ground, and demand for action was growing. Team members felt that they had to take adva ntage of the favorable polit- ical climate created by a succession of rmini,ters who were at least not against tobacco control action, if not explicitly for it. Above all, they wanted to act while Marcos Moraes was director of INCA. He strongly supported public health initiatives and was interested in moving tobacco control forward. The team recognized the need to consolidate the process of creating part- nerships and attracting qualified people wita varied professional back- grounds to the program. With this goal in mind, in 1994 INCA organized the First National Congress on Tobacco Use, wvith t:t e support of FUNASA and the CCCTB. Over 400 people attended t]-te meeting, including politi- GOVERNMENT LEADERSHIlP IN TOBACCO CONTROL. 45 cians, Catholic Church leaders, lawyers, teachers, physicians, nurses, psy- chologists, and media professionals. During the congress, the WHO awarded INCA the Tobacco or Health Prize for its work on tobacco control. As a result of the congress, a partnership among the main health pro- fessional associations began. Meetings were held in 1996 and 1999. In 2000, 21 associations met and produced the Conisenisius on tile Treat11nent Of Tobacco Users, which INCA published in 2001 and is distributing to health professionals across the country. The Consenisuts was the first document published in Brazil that provided a technical guide for health profession- als who want to help smokers quit (Ministry of Health, INCA, and CON- PREV 2001a). Throughout the 1990s, tobacco control events became stronger and more frequent, with the yearly celebrations of World No Tobacco Day (May 31) and the National Day Against Tobacco (August 29). The National Day Against Tobacco, which promotes a link between sports, arts, and not smoking, has become more and more popular across the country. The NTCP team at INCA coordinates the central production of all publications and advertisements with the aim of improving communica- tion through the use of a single message and image. Restricting Tobacco Advertising and Promotion At the end of 1994 the NTCP team handed the health minister a daring initiative-a proposed bill banning all direct and indirect advertising and promotion of tobacco products. The bill would also require that packages of tobacco products display the Ministry of Health's six rotating health warnings. When the proposed bill arrived in Congress, an intense debate about its constitutionality erupted between the government on one side and the tobacco industry and its allies (advertising professionals and representa- tives of television and radio advertisers) on the other. The industry and its allies argued that the bill was a crime against freedom of information. The NTCP team welcomed the debate because it provided additional public- ity about the harmful effects of tobacco use. The outcome was weaker legislation (Law 477/1995) that merely restricted tobacco advertising to the hours between 9 p.m. and 6 a.m. and included less assertive warnings on cigarette packs. For example, the word "may" was added to the warning about heart attacks so that instead of stating "Tobacco causes heart attacks," it read "Tobacco may cause heart attacks." Tobacco control measures in the 1990s were not as strong as advocates would have liked, but they seem to have had an impact on cigarette con- sumption. Decreases in real prices in 1990-91 and between 1992 and 1994 46 LUISA IV[ DA COS1A E SILVA GOLDFARB Figure 3.1. Trends in Cigarette Consumption and Real Prices, Brazil, 1983--94 Index (1983-100) -- CDnsumption index 140 -u~ Average real price index 130 120 110 100 90 80 70 60 50 - I r I 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 Soutrce: Silva and others (1999). should have led to an increase in consumption.. as had happened between 1983 and 1986 (a period of extremely high inflation). Figure 3.1 shows that consumption fell in the late 198()s and early 1990s, suggesting that the usual effect of lower prices was counteracted by other factors such as health warnings on cigarette packs, limits on indoor smoking, and restric- tions on tobacco advertising (Silva and others 1999). Economic Meas ures Con!sidered In 1995 the NTCP team decided that it wvas time to consider adding eco- nomic measures to existing tobacco control efforts,. Published evidence from other countries indicated tlhat an increase in prices would lead to a decrease in tobacco consumption Health Mini ster A dib Jatene ordered an econometric study to evaluate the impac- of a price change on consump- tion and supply in Brazil. The study provided the NTCP team and other tobacco contro] players with the information rLeededl to coax the financial and economic sector to work with them. In the meantime, worried about the contents of i:obacco products sold in Brazil, the NTCP team sent five samples of the most popular cigarette GOVERNMENT LEADERSHIP IN TOBACCO CONTROL 47 brands to Canada for content analysis. NTCP staff compared the results with limits for tar, nicotine, and other components set by countries where the contents of tobacco products were controlled. The Brazilian cigarettes exceeded most limits. Both the econometric study and the content analysis proved valuable in 1999 when they were used to support the inclusion of tobacco in the list of substances regulated by the National Sanitary Vigilance Agency (ANVISA), the Brazilian counterpart of the U.S. Food and Drug Adminis- tration. Both studies and their results were summarized in Brazilian Ciga- rettes: Analyses and Proposals to Reduce Consumption (Silva and others 1999). The States Become Involved The NTCP team knew that its activities had to be improved and expanded if the program were to succeed. These efforts depended, as usual, on polit- ical decisions; policymakers and decisionmakers had to be committed to the program. Accordingly, at the end of 1995 the NTCP team proposed that the health secretaries of all the Brazilian states be invited to the NTCP's annual evaluation and planning meeting. The meeting, chaired by Health Minister Jatene, was held during the national meeting of the State Health Secretaries Council. It included the first appraisal of NTCP management in the states and a presentation of the program's needs for resources for local action. This was a historic moment: tobacco control finally became part of the health agenda in all the states. An agreement was reached in which finan- cial resources were transferred from the central to the local governments. Those resources could be used only for a work plan developed and assessed annually by the states and INCA together and supervised by INCA. Implementing Decentralization The increased involvement of the states reinforced the NTCP team's com- mitment to decentralization. To be successful, the program had to reach people across the country, but Brazil's huge area and large population cre- ated a challenge. The NTCP team took advantage of the existing network of the Ministry of Health Management System to develop a decentralized program for tobacco activities. In 1996 NTCP team members gave management training courses to staff from all 27 state health secretariats and 300 municipal health secretariats. This helped develop a large, well-trained national workforce at the local level. That 300 municipalities were willing to allocate funds and to send their staff for training was an indication of the demand for the courses and of commitment across the country. The relatively large numbers of people 48 LUISA NM. DA COSTA E SILVA GOLDFARB involved helped persuade policymrkers and decisionmakers to allocate federal funds to build capacity for local NTCP staff and other agents. Since 1997, training courses have been held all over the coumtry. Two books have been written about the experience: Basis for the Imple- mentation of a Tobacco Control Program (Golf farb and others 1996) and Prac- tical Guidelines for the hmplk'nentation of a Tobaccc Control Program (Silva and others 1998a). The local health sec etariats use these books to prepare courses and train staff. In addition, the WHO Tobacco Free Initiative, now coordinated by Vera L. da Costa e Silva, uses these I exts and the method- ology they describe for simnilar actions in other count-ies around the world. INCA Becomles a WHO Ccllaboratir'g Center Recognizing the need to encourage new people to take part in the NTCP, INCA supported the state of Ceari in northeastern Brazil when, in 1996, the state hosted the Second National Congress on Tobacco Use. This congress had twice as many participants as the first one, helc. in 1994, and it estab- lished the basis for a National System for the E valuiition and Surveillance of Tobacco Control. Since 1996, the congress has been held in different regions. Each congress produces a document, "Final Recommendations," that establishes the basis for further action on tobacc3 control in Brazil. At the 1996 congress INCA's director, Marcos NMoraes, announced an expansion of the responsibilities of NTCP staff. Within their ambit would be the National Coordination of Tobacco ContTol and Primary Cancer Pre- vention (CONTAPP), which included the NTCP and other prevention programs for cancer risk factors. At the end of 1996 Brazil was designated a 'NHC Collaborating Center for the Tobacco or Health Program. With this move, INCA had achieved both national and international importance: it was now responsible for providing information on the WHO Tobacco or Health Program to Brazil and beyond-to Latin America, and to Pcrtuguese- and Spanish-speaking countries all over the world. The national coordination bulletin Totacco News became a key tool for INCA in fulfilling this mandate. Published in Portuguese since 1992 and in English and in Spanish since 1994, Tobacco News was distributed to 100 institutions and individuals around the world and to 19 Latin American countries, in addition to 10,000 subscribers in Brazil. In 1996 its scope was widened to include other risk factors. It was also used to set out the guidelines for the Collaborating Center's activities, Another publication, Data and Facts, was created in 1999 to ccmmLnicate news about tobacco issues in Brazil and around the world, and about the NTCP's actions dur- ing the negotiations for the WHO Framework Convention on Tobacco Control (FCTC). GOVERNMENT LEADERSHIP IN TOBACCO CONTROL 49 In 1996 INCA began the first of a series of research projects to support its tobacco control efforts. The first research study evaluated a pilot pro- ject on educational interventions in four schools in Rio de Janeiro city. The pilot project was designed to provide experience and to test materials for the National School-Based Health Knowledge (Saber Sauide) Program. In 2000 an analysis of the project's research results was presented in a pub- lic health master's degree thesis, which demonstrated that the interven- tion significantly reduced tobacco experimentation among students (Goldfarb 2000). More International Involvement From November 1996 on, 12 professionals were on the staff of CONTAPP (which included the NTCP). In addition to the four physicians who had worked there from the beginning and another physician, they included a lawyer, a teacher, a chemist, a psychologist, a nutritionist, a nurse, and an epidemiologist. Attracted by the dimensions of the NTCP and the avail- ability of NTCP/INCA facilities and staff support, two major events took place in Rio de Janeiro in 1998: the annual meeting of CLACCTA and the Seminar for an Agenda on Tobacco Control Priority Research for Latin America and the Caribbean Islands. The first event brought together representatives from 19 countries and from the CDC, the Pan American Health Organization (PAHO), the WHO, and the American Heart Association. CONTAPP staff took the opportunity to present Brazil's tobacco control activities and plans in detail. This led to discussions of the possibility of using the Brazilian experience to develop pilot studies in other countries throughout the region. The second event, supported and chaired by Research for Inter- national Tobacco Control (RITC)-a secretariat of the International Development Research Centre (IDRC) in Canada-brought together researchers from a variety of institutions. As a result of their participa- tion, many of these institutions adopted tobacco control as a priority action item (RITC 1998). Research Continues Research on tobacco-related topics continued on several fronts. In 1998 the "Study on the Impact of Tobacco Use on Death by Heart Attack among Women Aged between 35 and 59 Years in Rio de Janeiro" was the subject of a doctoral thesis in public health that showed a positive association between tobacco use and myocardial infarction among women in the studied population (Silva 1999). 50 LUISA M. DA COSTA E SILVA GOLDFARB To expand research efforts, the Ministry of Health, through INCA, began developing research links with universities. In 1998 a partnership with Johns Hopkins University in the UnitedL Statcs was signed to carry out a study on smoking behavior, passive smoking, and the determining factors for nicotine levels in saliva in Rio de Janeiro. The study was com- pleted at the end of 2002. Preliminaary data show a drop in smoking preva- lence in Rio among adults (age 15 years arnd older) f rom 30 percent in 1989 to 21 percent in 2002. The reduction is strongest among the 16-24 age group and is larger for men than for women. Of the smokers interviewed, 85 percent were aware that passive smoke causes harm; 53 percent sup- ported a total smoking ban in restaurants; 70 percent supported a ban on all advertising; and 76 percent supported a ban on sports sponsorship by the tobacco industry. With a view to stimulating research, the NTTCP team began reserving part of its budget for studies within the states to evaluate local educa- tional interventions in schools, heatth units, and workplaces. This initia- tive has had limited success so far becauise i has been difficult to find qualified professionals at the local level to conduct the evaluations. In 1999 NTCP staff broadened the scope of research to investigate other health issues in addition to tobacco. Experts from different areas were invited to formulate questions for the National Household Survey on Risk Behavior and Related Morbidity frorn Noncommunicable Diseases, funded by the World Bank and by two institutions associated with the Brazilian Ministry of Health: FUNASA and the National Centre for Epi- demiology. Data collection began in 2002, and preliminary data will be available in 2004. Also in 1999, the NTCP tobacco contro] pilot project in workplaces was evaluated and described in a master's thesis in occupational health (Feitosa 1999). This study supported the firdings of previous research showing a positive relationship between educational interventions and reduction in tobacco use. It formed the basis for the NTCP's workplace programs. In 2000 another study evaluated the Tobacco-Free INCA Program, designed to make INCA's buildings tobacco free. This study, which also showed a positive relationship between educational interventions and reduction of tobacco use, formed the basis for NTCP programs in health service units (Ministry of Health 2000b). Support for strengthening the program's outreach to health profes- sionals came from a master's thesis in public health on physicians' atti- tudes toward tobacco use, tobacco users, and their efforts to stop smoking (Cavalcante 2001). Physicians' attitudes and preconceptions about tobacco use, its health effects, and its addictiveness were shown to affect their support for and use of training and related rmaterials. GOVERNMENT LEADERSHIP IN TOBACCO CONTROL 51 The commitment to research continues. Important surveys were carried out in 2002: the National Survey on Tobacco Use among students, sponsored by a partnership between the Brazilian states and INCA/Ministry of Health, and the CDC/PAHO/WHO Global Youth Tobacco Use Survey in 13 Brazil- ian municipalities (1 funded by PAHO and the WHO, 5 by INCA, and the rest by the Brazilian Health Ministry and by state health secretaries). Political Will Brings Increased Support With the CLACCTA and IDRC events in Rio de Janeiro and the ongoing national activities, 1998 had been an intense year, but it still had a surprise in store. In December INCA's new director, Jacob Kliegerman, transferred early cancer detection to the NTCP team. Already in charge of programs for other cancer risk factors, this small team now had to balance its expanded responsibilities with those of the NTCP. Vera L. da Costa e Silva became the general coordinator of all prevention and detection programs, and the author took over coordination of risk factor prevention, in which the NTCP was involved. The NTCP team members recognized that the time was right for greater action: they had physical facilities, were highly motivated, and continued to have the support of INCA's director. Above all, they had the health min- ister, Jos6 Serra, on their side. Serra was more than supportive: he became NTCP's leader and canvassed the president for his support as well. Stronger Laws on Tobacco From 1998 on, the framework of laws controlling tobacco and tobacco use broadened as a result of Serra's efforts (Ministry of Health, INCA, and CONPREV 2001d, 2001e). The first was Ministry of Health Ruling 2,818 in 1998, which banned smoking in the ministry building. A crucial next step was the approval in January 1999 of Federal Law 9,782, which established the ANVISA. With the creation of this agency, Brazil became a world leader in regulating and controlling the production, content, and adver- tising of tobacco products. Also in 1999, Ministry of Health Ruling 695 mandated new, more assertive warnings to be published on cigarette packages. Two phrases were particularly striking: * "Nicotine is a drug and causes addiction"-which represented a major victory against the industry * "Smoking causes sexual impotence"-which put Brazil, only the sec- ond country in the world to adopt this warning, in the forefront of anti- tobacco action. 52 LLISA NI. DA COSTA E SILVA GOLDFARB Next, ANVISA Resolution 320/99, requiring annual registry of tobacco products and reporting by the industry, was propos:!d. Companies wou]d be required to pay a fee for each brand they produc-d. The money would have been used for funding tobacco contiol initiatives such as the Labora- tory for Tobacco Analysis and the Centre for Clinical Studies on Nicotine Addition in INCA. This resolution vjas later replaced by Resolution 105. The National Conimissio,' on1 Tobacco Use In August 1999 Decree 3,136 created the National Commission on Tobacco Use (NCTU) to prepare Brazil for the corning world negotiations on the FCTC. The ministries representecL on the com-rrLission are Inland Revenue, Health, Education, Development, Industry ancL Trade, Work Relations and Employment, Agriculture and Supply, Foreign Affairs, and Justice. Each minister nominates a representative. The presid ent o r the commission is the health mninister, and the executive secretary is from INCA. By involving all these ministries-not only the Ministry of Health--the NTCP became a stronger program, with many ministries contributing to a common tobacco control effort, supported and implemen.ed by stal-es and municipalities across the nation. Since its establishment, the NCTU has listened to many sectors of society, including tobacco proponents, to gather as much information as possible to support Brazilian actions at home and abroad. Its agenda includes important tobacco control issues within Brazil, such as a prov sional measure to ban tobacco vending machines, which make it mruch easier for children and teenagers to buy cigarettes. One way that the tobacco in dustry tries to increase tobacco consumption is to make buying tobacco prodlucts as easy as possible. The NCTU has held regular meetings Lo analyze its white paper for the FCTC that establishes the basis for the Brazilian position at meetings of the Intergovernmental Negotiating Body. It has also met with the Brazil- ian Tobacco Growers Association (AFUBRA), at that group's request, to discuss the growers' concerns about the FCTC (Mirnistry of Health INCA, and CONPREV 2001f). In August 2000 the NCTU held the first public hearing on the FCTC. The hearing was designed both to inforrn the publtc and to receive input about Brazil's participation in the FCTC. Over 15 dEays, 30 institutions and interested individuals, includirLg representatives from tobacco-related business, presented their interventions in favor of or against the FCTC/WHO document. Swift Action and Strong Support: A Legislative Victory Studies carried out abroad have confirmed the effectiveness of a compre- hensive ban on tobacco product advertising in reducing tobacco con- GOVERNMENT LEADERSHIP IN TOBACCO CONTROL 53 sumption, especially among young people (Saffer 2000). In 2000 Brazilian society was ready to take this step, and the Ministry of Health decided to present an antitobacco bill to the Congress. The NTCP team knew that dealing with the tobacco industry would be a tough task. The industry had reacted fiercely whenever faced with restrictive legislation in other countries. Experiences such as the rejection by the U.S. Congress of pro- posed changes to legislation in 1988 suggested that rapid action would be the best way to get changes through. Information on the new tobacco control strategy had to be provided quickly to key individuals and to the Brazilian people. The NTCP team focused on preparing to neutralize industry's attempts to interfere with the planned legislation. In May 2000 the health minister sent to Congress Bill 3,156, which would limit the advertising of tobacco products to the point of sale only. The action had begun. Canvassing Public Support To gain public support for the new bill, the Ministry of Health released the television movie Traficanite (Trafficker), together with outdoor display advertisements and advertisements in the main Brazilian magazines. The campaign had enormous public impact. The movie showed the correla- tion between nicotine consumption and use of other drugs, and the simi- larity between drug dealers and the tobacco industry. At the same time, the ministry sponsored the exhibition Seeing through the Snloke, designed to attract public attention to the tobacco issue, promote discussion, and inform people, especially teenagers. The exhibition included publicity films, sculptures, videos, photos, and interactive installations in Sao Paulo, Brasilia, and Rio de Janeiro. Soon afterward, the Ministry of Health released the movie Jornalista (Journalist), in which a real person, a journalist, talked about his legs being amputated because of thrombosis caused by his dependence on tobacco. The ministry's bold actions stirred enormous public interest. The press fol- lowed the issue closely and interviewed NTCP staff, INCA's director, and the health minister many times in the months before Congress voted on the bill. To assess the campaign's impact, people in 100 municipalities were sur- veyed about the movie Traficante; 97 percent approved of it. In a national sample, 73 percent said they knew of the government's campaign against smoking, and 94 percent approved of the comparison between tobacco and drugs. For the movie Jornalista, public recall was almost 90 percent, one of the highest ever for a government prevention campaign (Ministry of Health and ASCOM 2000). The industry reacted noisily, saying that it was surprised both by the government's action and by the content of the bill and that the law was too radical. It looked to advertising agencies and the public for support, 54 LLJISA M. DA COSTA E SILVA GOLDFARB and it lobbied members of Congress to include alcohol in the law. Health Minister Serra responded quickly by saying that thos2 who wanted alco- hol included in the law should be considered tobaccc industry lobbyists. That was enough to defuse any attempt by mernbers of Congress to sup- port the countercampaign. The Importance of Partne- iships The government now moved to enlist Droad support by developing a con- tact network of 3,000 institutions. Informabon was sent out through the Internet, and handouts (similar t-o those produced by the European Union) were distributed that spelled out why tobacco advertising and sponsorship should be prohibited. [NCA's ]internet site included a discus- sion space that received about 250 comments and queries every month. E- mail addresses for members of Congress wvere publicized, and citizens sent them thousands of messages. An interesting partnership was set up w-ith the nongovernmental orga- nization (NGO) Rede de Desenvolvimento Humano (REDEH), a collec- tion of 5,000 pro-woman and citizen organizations. About 350 community radio stations belonging to CEMINA, a member of REDEH, aired spots warning about health damage from tobacco use and giving information on the proposed law. The Brazilian Societies of Cardiology ancl Pediatrics, the Federal Med- ical Council, the Federal Council of Dentists, the Federal Nutrition Coun- cil, and the Brazilian Medical Academy all showed their support for the law by making public statements on its urgency ancd importance. Many international institutions also supported the lawv, bec2 use of Brazil's posi- tion as a major tobacco producer and exporter and because of its potential to serve as an example to other countries. Induistry Action Meanwhile, the tobacco industry and advertising agencies stepped up their actions. Tobacco proponents said they were puzzled by the "sensa- tionalistic and radical way" the go vemmenEt was dea ing with the matter. They claimed that Brazil's constitution guaranteed freedom of commer- cial expression for the tobacco industry. The industry sent letters to 1,400 radio stations and 200 television sta- tions condemning the ban on tobacco advertising and claiming that "to for- bid [advertising] is to deny freedoni of expression, the right to information, and consumer's freedom of choice." They recornmeended that the media spread a message emphasizing freedom of creation and expression-the "oxygen of publicity." GOVERNMENT LEADERSHIP IN TOBACCO CONTROL 55 The media generally tried to present both sides of the discussion. But not everyone in the media had the same clear understanding of what was at stake. One newspaper published a message favoring tobacco and stat- ing that "the president of Souza Cruz [Brazil's major cigarette producer and the Brazilian arm of British American Tobacco] defends the freedom of the market and maintains that the government ought not to interfere in people's lives or force them to be happy, healthy, or good." In response, the NTCP/INCA distributed to the media a statement say- ing, "There is no freedom without responsibility. Freedom to advertise cigarettes may be restricted constitutionally for health reasons, particu- larly because it concerns a product that kills half its consumers and uses misleading advertising messages." To widen the focus, two public debates were organized before the Commission of Constitution and Justice and the Commission of Social Affairs in the Brazilian Senate. The debates between lobbyists on both sides revolved mainly around freedom of expression, but the economy was also a key element. AFUBRA made a brief presentation and asked questions. As the controversy boiled, the industry promoted a new strategy to bypass the existing law that prohibited smoking indoors: "smokers' lounges," with comfortable armchairs and complex air conditioning sys- tems that were supposed to extract smoke and clean the air. (Considerable evidence shows that these air conditioning systems are not effective in protecting health; see Tobacco Free Kids 2001.) The promotion of smokers' lounges used images that associated smoking with a comfortable lifestyle. On December 13, 2000, the tobacco control bill passed the Senate and the Chamber of Deputies, and on December 27 President Fernando Hen- rique Cardoso signed Law 10,167. Tobacco advertising now could appear only inside sales points. The industry reacted by trying to increase sales to compensate for those lost as a result of the new law. A new marketing strategy focused publicity at sales points, the only places it was still allowed. The industry increased the number of sales points and redesigned some of them as "tobacco shops," a new concept featuring attractive layouts and displays of antique and modern tobacco-related devices that appeal to art appreciation and curiosity. Sometimes a pipe maker demonstrates her craft. (Most pipe makers are women.) The National Commission Deals with Rumors The passage of Law 10,167 was a victory for tobacco control advocates, but it did not mean the battle was won. Skirmishes continued regarding many points. A crucial moment for the NCTU came in March 2001 dur- ing one of its routine meetings in southern Brazil. NCTU members 56 LUISA r. DA COSIA E SILVA GOLDFARB planned to use the occasion to meet wit!h 230 local people, including farmers, university teachers, agrncultural technicia is, tobacco industry workers, and members of syndicates, trade unions, and religious congre- gations, to discuss issues raised by the FCTC, particularly those related to alternative crops. At first, the meeting did not go as planned, as rumors circulated that the government was going to ban tobEacco growing. The ]nternational Tobacco Growers Association released a letter that presented En inaccurate analysis of the FCTC's intentions, causing great anxiety anmong workers in the region. At the time, the author was executive secretary of the NCTU, and she produced a series of papers to explain the goverrinment's position. The media became involved, and the event had greater repercussions than expected, but the message got through: Brazil was planning for a future of lower tobacco demand. Fobacco control measures around the world, fol- lowing FCTC recommendations and actions, would cause demand for tobacco products to drop, and supply would bc affected. Because Brazil is a major producer and exporter of tobacco, it had to anticipate this process so that adjustments could be as srnooth as possible. The government was seeking ways of gradually substituting other crops for tobacco. These arguments neutralized the rumors, and the farmers became less wary of the government representatives. They finally joined the discus- sion on what kind of help they needed and whether direct technical, financial, or operational support should be provided. The NCTU sug- gested that farmers, industry, anLd the gove-rnment work together to answer these questions. The commission had tirned its detractors' attacks to its advantage (Ministry of Health and others 2001). More Tobacco Control Legisla,tion On March 28, 2001, ANVISA pub] ished Resolution 46. Among other pro- visions, the resolution sets maximum levels of tar, nicotine, and carbon monoxide allowed in cigarette smoke released by tobacco products sold in Brazil, wvhich would bring them into ire with European Union limits (table 3.1). Resolution 46 also requires that every cigarette package carry informa- tion on the levels of these substances and t]he v.warning, "There are no safe levels for the consumption of these substances." The resolution was the first in the world to forbid the inclusion of any descriptive words or phrases such as "light," "ultra ligalt," "low levels," ' mild," "soft," "mod- erate levels," "high levels," or any others that might mislead consumers about the concentration of the listed substances. Through heavy lobbying, the industry succeeded in postponing the application of the law from 2001 to January 2002. At the time, the reason the delay was requested was GOVERNMENT LEADERSHIP IN TOBACCO CONTROL 57 Table 3.1. Maximum Levels for Three Harmful Cigarette Smoke Ingredients, Brazil and the European Union (milligrams per cigarette) Tar Nicotine Carbon monoxide Brazil January 2002 12 1 12 September 2002 10 1 10 European Union September 2000 10 1 10 Source: European Union, 2002. unclear, but eventually it became obvious that the companies wanted the delay so they could launch new marketing campaigns using new package designs, colors, and layouts that would be associated with "light" ciga- rettes. After the prohibition came into effect, they could use these designs and colors to convey the idea without using the actual word "light." On World No Tobacco Day, May 31, 2001, Health Minister Serra sent Congress another regulation toughening the legislation against tobacco advertising. Provisional measure 2,134/30 was signed and became effec- tive in January 2002. Following Canada's example, the measure requires that the warnings on cigarette packages and advertisements be accompa- nied by a picture showing graphically what they mean. At the end of that highly productive year, Resolution 105 was pub- lished. It required that all tobacco companies-manufacturers, importers, and exporters-be registered and submit annual reports to ANVISA on their tobacco products, the products' compositions, and sales and pro- duction levels. Education: The Basis of the NTCP The history of Brazil's tobacco control efforts shows how a steady buildup of commitment and action can lead to success. Together, education and legislation form the foundation of this achievement. The "Cascade" Systemfor Training Early on in the struggle, NTCP team members recognized that they alone could not provide all the training needed to keep the program moving forward. The team therefore developed a cascade system to multiply its training efforts. The federal team (that is, the NTCP team) trains the staffs 58 LuSA :M. DA COSY-A E SILVA GOLDFARB of state health and education secretariats, who then train staff from municipal health and education secretariats. They, in turn, train profes- sional workers at workplaces-schools, health units, and so on-and these professionals use their training to reach out to the general public. The NTCP training prepares local state and municipal agents for action at four activity levels. This staged set of actions, combined with the cas- cade training scheme, guarantee's a netwfork of capable people in the health and education systems. They work together within a framework that supports all the activities needed to adl. ance tobacco control. The four levels are as follows: Level I * Deciding on the local political, physical, and adrinistrative structures for tobacco control initiatives * Planning and evaluating local programs and activities • Conducting public and media relations and keeping the tobacco con- trol theme on the media agenda * Giving general information talks on tobacco and the implications of its use and production * Coordinating tobacco control activities at the loctl level * Learning epidemiology basics Level 2 * Within the local partnership of hea] th and education secretariats, developing and coordinating continuous educational actions through- out the year across three community chanrnels-schools, health units, and workplaces-with agents from the Family Health Program and the Community Agents for Health Program Level 3 * In partnership with those responsible for epidemiology, carrying out surveys and research projects and implementing local initiatives of the National System of Evaluation and Surveillance on Tobacco Level 4 * Encouraging the development of, proposing, and lobbying for ade- quate legislation and economic measures * Providing techniques and support materials for the treatment of nico- tine addiction By 2002, teams in 26 states and the Federal DistrLct (Brasilia) had been trained and were training others within levels 1 ancl 2. The work is being carried out in 3,150 cities-almost 60 percent of all cities in the country- GOVERNMENT LEADERSHIP IN TOBACCO CONTROL 59 by 12,239 trained professionals (Ministry of Health, INCA, and CONPREV 2001b). Training for level 3 began in 2000 in all states and in Brasilia. Level 4 training began in 2001 within the Help Your Patient Stop Smok- ing Program in five regions of the country. NTCP staff set priorities among routine counseling, group, and individual sessions according to the Con- sensus on Treatment of Tobacco Users (Ministry of Health, INCA, and CON- PREV 2001a). To provide better support for these actions, the Tobacco Studies Laboratory Division at INCA's Centre for Clinical Studies on Nico- tine Addiction (CCSNA) is studying the use of drugs to help people stop smoking. Through clinical trials, it will investigate the efficacy of nicotine replacement therapy, on its own and combined with behavioral interven- tions. The information from the studies will be used in deciding whether to subsidize public programs that support quitting smoking. Also as part of level 4, at the beginning of 2001 a national plan for encour- aging legislative strategies and actions was drawn up. The plan helps local advocates stimulate the creation of laws, promote lobbying, monitor legis- lation, and reinforce tobacco control legislation at the local level. Tobacco Control Education in the Workplace, in Schools, and in Health Units The most popular educational actions are the campaigns and celebrations, which are designed primarily to provoke, inform, and promote discussion. But these events are not enough to create the changes in attitudes, habits, and behavior needed to cut tobacco use. Continuous day-to-day actions are essential in health units, workplaces, and schools. In Brazil these actions are supported by experiences from the pilot studies mentioned ear- lier and compiled in the manuals Implementing NTCP in Health Units, Imple- menting NTCP in Workplaces, and Implementing NTCP in Schools. The program in health units and workplaces aims first to achieve a tobacco-free environment through the Tobacco-Free Places Program. It then supports people who want to quit smoking through the Helping Your Patient Stop Smoking Program. These programs are led by health professionals, who are trained to become "multipliers." They implement the program inside their institutions and train others, who then train staff members and even clients. The training helps people understand their responsibilities as role models and how this relates to day-to-day behav- ior, particularly in health units. Respect for others is emphasized, with the aim of achieving a better quality of life for everybody. In the workplace and in health units. In early 2002 the Tobacco-Free Places Program was already under way in 3,150 cities, and 1,042 compa- nies were registered in the workplace program. Of these, 358 were taking action, and 83 had finished the process and were totally tobacco free. 60 LUISA XI. DA Cos rA E SILVA GOLDFARB Among health units, 530 were putting t ie pi-ograrn into practice (Min- istry of Health, INCA, and CONPREV 2001b). In schools. The statistics on first use of tobacco by children and adoles- cents at the beginning of this chapter highllight the need for antitobacco programs aimed at young people. The Saber Saude health knowledge program was developed to meet this need. With its emphasis on the qual- ity of life and health promotion, the program covers more than tobacco control issues; it also deals with alcohol, exposure to sun, diet, physical activity, sex, and occupational hazards. Under the program, trained teachers develop c assroom activities as they would for other subjects. The activities are related to the school's overall community life and to students' interests. Modules such as "The Smoke-Free School" can be adapted to each school. These program activ- ities form themes across all disciplines, as required by the national cur- ricula of the Ministry of Education: heaLth, environment/ecology, ethics, citizenship/politics, and sexuality (Silva and others 1998a; Goldfarb and Monteiro 1999). The Saber Saude program has been welcomed by educators. National implementation began in 1998, and by 2002, 4,853 workers had been trained at the state education secretariats in 2,247 cities. By January 2002, 5,251 schools were registered in the program, and 2,983 of them had already trained between 70 and 100 percent of their teachers, for a total of 62,024 teachers. These teachers instruct 1,227,358 stLudents in grades 1 to 8 (Ministry of Health, INCA, and CO\JPREV 2C01c). Although this is not a huge number when compared with the total school population, it is still very encouraging. Many technical schools and universities are adapting the program for their own use, but the results of these initiatives are not yet available. Legislative Action: EduLcation's Partner Education alone would be a sliw road to success in tobacco control. Together, education and legislation move tobacco control efforts more rapidly toward their goal. In Brazil legislative actions take place in the wake of and in support of educaticn initiatives. Eclucation, in turn, sup- ports legislation by teaching people about the law, why it exists, and how it is enforced. It also raises awareness that results rn increased advocacy and support for tobacco control. Legislation-related actions inclucLe: • Creating and updating a database on tobacco legislation now in force and planned across the count-y * Monitoring voting by political representatives GOVERNMENT LEADERSHIP IN TOBACCO CONTROL 61 * Providing information to political representatives * Researching technical information * Providing advice and comments on proposed bills * Lobbying. The biggest challenge is informing people about the law and encour- aging them both to obey it and to help enforce it. Helping people become better citizens involves changing attitudes and behavior. Legislative actions, like educational ones, are carried out by the three lev- els of government: federal, state, and city (municipality). In 2000 alone the Congress sent 59 tobacco control bills to the NTCP for analysis. NTCP staff provide clear technical and political information to ensure that the pro- posed law supports public health interests. Feedback from the NTCP can result in changes being made to a bill or can even lead to its withdrawal. At the state level, 72 laws regulating the publicity and consumption of tobacco have been passed, and at the municipal level, 331. Of the state and municipal laws, 73 percent have been approved since the NTCP's estab- lishment (Ministry of Health, INCA, and CONPREV 2001d). The Other Side of the Picture: What Stimulates Consumption? Brazilian tobacco advocates have made great progress in controlling tobacco use, despite the opposition of a huge international industry. The tobacco industry has invested an enormous amount of money in direct and indirect tobacco advertising to entice people to smoke. In 1994 US$6.6 bil- lion was spent on direct tobacco publicity in Brazil (Nielsen Institute 1996). Indirect tobacco advertising in Brazil and elsewhere in the world has associated tobacco use with sports, arts, music, popular artists, fashion shows, and celebrities by sponsoring events that involve these activities and people. Events related to education, ecology, and environmental protection have also become targets of tobacco sponsorship. In this way, the industry seeks to associate tobacco products with healthy activities to create a posi- tive public image. For example, in 1999 tobacco company-sponsored pro- grams Hortas Escolares (School Greenery Gardens) and Clube da Arvore (Tree Club) reached 3,700 rural schools, 120,000 students, and 5,000 teachers in the southern state of Santa Catarina. The programs praise the benefits of healthy foods and the importance of protecting the environment and pre- serving nature, and they teach students how to grow a school garden or make a reforestation camp (Souza Cruz 1999a). A similar program by AFUBRA, A Vida e Verde (Life is Green), dis- tributes seeds and teaches agriculture students how to plant them (AFUBRA 2000). In 1999 a partnership between AFUBRA, the Tobacco 62 LUISA NA/. DA COSTA E SILVA GOLDFARB Industry Syndicate (SI\DIFUMO), and other institutions created a new program, 0 Futuro 6 Agora (Thc FLture is Now), to train workers for jobs in agriculture. Souza Cruz, a major Brazilian tobacco company is one of the sponsors of the government education program Alfabetizacdo Solidaria (Support- ive Literacy Program) and has, through its own ini dative, started the pro- gram Educar (Educate) to teaclh i literate adults and provide technical training in agriculture. The company is also one of the sponsors of the environmental program Onda Azu (Blue Wa ve), which has been interna- tionally acknowledged and is led by the important Brazilian environmen- talist and popular music singer Gilberto Gil (SouzT1 Cruz 1999b, 2001). Another campaign, directly focused on younger people, produced advertisements with a double meaning: "Smoking after 18. That's Legal!" (Fumar s6 com 18 anos. Isso 6 legal!) and "Smoking? Only with an Iden- tity Card" (Fumar? S6 com carteira de identidade) (Goldfarb and Mon- teiro 1999). The campaign presented itself as being supportive of the leg- islation that prohibits cigarette sales to teenagers younger than age 18, but in fact it was part of a worldwide carnpaign by the tobacco company Phillip Morris to reinforce the perception among young people that smok- ing is an adult activity-a prime reason for its attraction for youths. All these publicity campaigns reveal the industry's keen interest in establishing a positive social irmage, particularly among young people. This interest coincided with the implementation of the NTCP's Saber Sauide program, which is aimed at teaclhers and students and focuses on health and the environment. Low Prices Enicourage Cotisuniption The low price of cigarettes in Brazil is another factor that has encouraged consumption. As shown in figtre 3.2, Brazilian cigarette prices are rela- tively low by world standards, even though tax rales on cigarettes are rel- atively high (Sunley, Yurekli, and Chaloupka 2000: 421; Guindon, Tobin, and Yach 2002). Studies in Europe, Canada, and the United States, as well as in Brazil, show that a 10 percent price rise causes a 3 to 6 percent decline in con- sumption. Among teenagers, the impact is even greater and may be as large as 14 percent in Brazil and 23 percent in Canada (Sweanor 1992; Townsend, Roderick, and Cooper 1994; European Union 1995; Silva and others 1999). Silva and others (1999) presented data showLng that cigarette con- sumption doubled between 1970 and 1980, from 72.7 to 142.7 billion units. It described the changes in anmual per capita consumption of cigarettes in Brazil since 1980, which has gone through several fluctuations, decreasing and rising with changes in real prices and ir,comes. Figure 3.2. Prices of Imported and Local-Brand Cigarettes, Selected Economies, March 2001 Pack of 20 at purchasing power parity 7.12 Hong Kong, SAR 6.23 New Zealand 5.74 Australia 5.42 1 United Kingdom -4.02 Canada 3.86 Sweden 3.71 1 United States of America 3.34 IChina ------3.-3'1 l taly Singapore 3.28 I Denmark 3.02 France 2.94 Germany 2.72 I South Africa 2.58 Poland 2.48 I Spain 2.42 Japan 2.42 Malaysia 2.40 Czech Republic 2.17'] Thailand 2.03 | Russian Federation 2.02 Chile 1.97 {Hungary 1.87 1 Switzerland 1.74 | Mexico 1.73 Argentina 1.61 T Republic of Korea 1.45 I Taiwan, Province of China; 1.23 Brazil 1.08 Indonesia I I I I I I I I I 0 1 2 3 4 5 6 7 8 9 10 Imported Brand (Marlboro) 63 Figure 3.2. (continued) Pack of 20 at purchasing power parity 47.38 Hong Kong, SAR 6.04_ New Zealand 5.50 United Kingdom 5.4=9 Aistralia 4.63 1 Singapore 3.87 I Canada 3.1|Sweden' 3.51 | United States of Amerrca 3.14 Denmark _3.02 China 2.67 Germany 2.61 South Africa 2.48 France 2.28 Malaysia 2.23 Italy 2.18 Japan 1 94 Switzerland 1.87 Poland' 1.80 ;Czech Republic 1.69 |Chile 1.67 | Republic of Korea 1.67 Hungary 1.44 Mexico 1.371 Thailand 1.37 | Israel 1.36 Brazil 1.36 Argentina 1.34 ISpain 1.30 | Russian Federation: 1.04| Indonesia 0.90 Taiwan, Province of China . I I F - l I I~ 0 1 2 3 4 5 6 7 8 9 10 Local Brand Note: The purchasing power parity index adjusts exchange rates for the relative cost of living in each economy. It allows a comparison of "affordability" rather than simply comparing prices. Source: Guindon, Tobin, and Yach (2002). Reprinted from Totacco Control 11 (1): 38 (2002), with permission of the BMJ Publishing Group. 64 GOVERNMENT LEADERSHIP IN TOBACCO CONTROL 65 Figure 3.3. Trends in Per Capita Cigarette Consumption by People Age 15 and Older, Brazil, 1980-99 -+--- Formal per capita consumption 2,500 -0--Informal per capita consumption (estimated) ^ Estimated total consumption 2,000 'U 2 1,500 w 1,000 .m 500 0 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 Source: Silva and others (1999). Among people age 15 or over, annual per capita consumption decreased between 1980 and 1984 because of inflation that reduced pur- chasing power (see figure 3.3). Between 1985 and 1986, annual per capita consumption returned to pre-1980 levels as a result of a decrease in the real price of cigarettes. In 1987 the price rose again, and, as a conse- quence, per capita consumption dropped the next year. In 1989 this ten- dency was temporarily reversed by an increase in salaries, which had been frozen, but in 1990 per capita cigarette consumption dropped to 1,752. Official data implied that in 1992 the level was 1,305, but this fig- ure hid the consumption of smuggled cigarettes and, on a lesser scale, counterfeit cigarettes, which were sold at lower prices and without any control. Actual consumption in 1992 was estimated at about 1,370 per capita. Until 1999 official consumption decreased and black market con- sumption increased, but total per capita consumption was thought to have remained stable at about 1,265. Even so, it was lower than the 1986 figure of about 1,950, leading to the conclusion that smuggling and the industry's massive investments in publicity had been counteracted by an effective tobacco control policy (Silva and others 1999; IBGE 2000; MDIC/SRF 2000). 66 ]LUISA l. DA COSTIA E SILVA GOLDFARB The Role of Smugglinzg One of the chal]enges of measurirng and combating tobacco consumption in Brazil has been the impact of smuggled cigarettes, which come in mainly from neighboring countries. Some smuggling involves "round- tripping," in which cigarettes are legally exported but, instead of reaching their alleged export destination, are smuggled back into the exporting country, There are no official figures, but Inlard Revenue's estimates for 1998 indicate that 58 billion cigarettes were sold on the black market. That figure corresponds to 40 percent of all cigarette consumption in Brazil. In 1999 around US$800 million was lost due to tax evasion related to ciga- rette smuggling (Ministry of lHealth 1999b; AFUBRA 2000; Ministry of Health, INCA, and CONPREV 2001d). In an attempt to curb smuggling, the Inland Revenue Office in Decem- ber 1998 imposed a 150 percent tax on cigarette exForts to South Ameri- can and Central American countries. Cigarette exports fell sharply, but soon afterward, exports of tobacco leaves rose (tobacco leaves are free of taxes). The number of cigarette-producing plants at sites just outside Brazil's borders increased (Ministry of Health, INCA, and CONPREV 2001d; Otta 2001). This shows that it is vitally important to monitor the tobacco industry's behavior so tliat smuggling can be understood and prevented. Resolution 105 was designed to provide such monitoring: as noted above, the industry must subJmit annLal reaorts to ANVISA on their tobacco products, the products' coniposition, and their sales and production levels. Lessons Learned Brazil's experience with tobacco contro] demonstrates how a public health program can succeed despite economic and administrative chal- lenges and strong resistance from commercial interests. The lessons to be drawn focus on the role of dedicated individue.ls and organizations in linking information, education, and legislation to create a potent force for change. The key lessons from the Brazilian experience are as follows: * Develop andfoster public commniitnent to tobacco control. Without this com- mitment, coupled with strong leadership, the NTCP and other advo- cates could not have achieved as much as they have. * Use a decentralized strategy to get tie message out. Brazil benefited from a strategy based on trainers instructing other trainers so that the message could be spread across the country. • Seek political support from those in power. Public commitment would accomplish little without the political lawill to spo isor legislation. GOVERNMENT LEADERSHIP IN TOBACCO CONTROL 67 * Participate in partnerships withl all sectors of society: professional associa- tions (particularly those in the health sector), the media, politicians, well-known artists and sports people, and religious organizations. These partnerships, based on respect and accurate information, were a great help in the process. They provided another means of getting the message out and helped persuade government ministers and the pres- ident to support tobacco control efforts. * Carry out and support research. Evaluations, prevalence surveys, econo- metric studies, opinion polls, political assessments, and other studies build a strong evidence base that allows sound decisions to be made and actions to be taken quickly. * Act quickly. Speed is essential in developing and approving legislation and educational programs and improving them. Changes should arise from the interaction between education and legislation. * Do not give in to indutstny pressures, no matter how innocuous the demands might seem. Agreements with the industry must be avoided; they only delay the adoption of new measures. There is not a second to be lost in this race. References ABIFUMO (Brazilian Tobacco Industry Association). 2000. Tobacco Industry Profile (in Portuguese). Brasilia. AFUBRA (Brazilian Tobacco Growers Association). 2000. 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IBGE (Brazilian Institute of Geography and Statistics). 20C0. "CENSO/Population National Data" (in Portuguesec'. Rio de :aneiro. Lopes, E. R., L. M. C. S. Goldfarb, G. A. S. IvIend onca, L. A. Marcondes, L. H. Sakamoto, and V. L. C. Silva. 1992. "Cancer and Environment." In M. C. Leal, P. C. Sabroza, R. H. Rodriguez, and P. 1X4. Bu,s, eds., Health, Environ- mnent anid Development. An 1J7te,-discipliniril/ Alallysis (in Portuguese), vol. 2: 197-249. Rio de Janeiro: HUCITFEC-ABRASCO. MDIC/SECEX (Ministry of Developrnerit, Industri,, and Commerce/Secretary of Foreign Affairs). 2001. Statistics Ai, non!al Report 2001 (in Portuguese). BrasiLia: MDIC. MDIC/SRF (Ministry of De\elopment, Indust-ry, and Cormmerce/Federal Income Bureau). 2000. "Informal N\arket 1992 to 2300" (in Portuguese). MDIC, Brasilia. Ministry of Health. 1999a. "Mvlortally Information System" (in Portuguese). Available at ; cited December 1999. 1999b. "Economic Actions for Tobacco Conxrol in Brazil: Reducing Smug- gling." 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Nielsen Institute. 1996. "Publicity Investment." In Getiflio Vargas Founidation Report (in Portuguese). Rio de Janeiro: Getdlio Vargas Foundation. Otta, L. A. 2001. "Cigarettes Become a Controversial Issue at Mercosur" (in Por- tuguese). 0 Estado Siao PauIlo, December 27, Economics section, p. 4. PAHO (Pan American Health Organization). 1992. Tobacco or Health: Status in the Americas. A Report of the Pan American Health Organization. Washington, D.C. Perez, M. D. C. 1990. "Erosion of Agricultural Practices at Cuenca of Pardinho River" (in Portuguese). Ph.D. dissertation. Rio Grande do Sul University, Zaragoza, Brazil. Quesada, F., and others. 1989. "Annual Needs of Wood as Fuel in Agriculture and Peccary Production on Small Properties in a Gaucho Municipality" (in Por- tuguese). Rural Social Econoniics 25 (1): 53-59. RITC (Research for International Tobacco Control). 1998. "Tobacco Control Research Pri- orities for Latin America and the Caribbean: The Rio de Janeiro Report." Ottawa. Rosemberg, J. 1987. Tabagismo, Serio Problema de Sauide Piblica [Tobacco Use: A Pub- lic Health Issue], 2d ed. Sao Paulo: ALMED Editora e Livraria Ltda. Saffer, H. 2000. "Tobacco Advertising and Promotion." In P. Jha and F. Chaloupka, eds., Tobacco Control in Developing Countries. New York: Oxford University Press for the World Bank and the World Health Organization. Silva, V. L. C. 1987. "Smoking Modification Behavior: An Approach to Teenagers in the Brazilian Anti-Smoking Program." In Annals of 6th World Conference on Smoking or Health, Tokyo, Japan. Amsterdam: Elsevier Science. 70 LUISA M. DA CCISIA E SILVA GOLDFARB .1999. "Study on the Impact of Tobacco Use on Death by Heart Attack among Women Aged between 35 and 59 Years in Rio dc Janeiro" (in Portuguese). Ph.D. dissertation. National Public Health School, (Dswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro. Silva, V L. C., T. M. Cavalcante, T. P. Feitosa, and L. M. _. S. Goldfarb, eds. 1998a. 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"The Health Consequences of Tobacco Us2 by Young People." In Pre- venting Tobacco Use anmong Youing People. 4 Reporit of the Surgeon General. Atlanta, Ga. WHO (World Health Organization). 1 998. "Growing up without Tobacco: Guide- lines to the World No Tobacco Day." Geneva. World Bank. 1999. Cuirbing the Epidemnic: Governnments ind 7tle Econo7nics of Tobacco Control. Development in Practice se-ies. XNashington, D.C. 4 Legislation and Applied Economics in the Pursuit of Public Health: Canada David Sweanor and Ken Kyle Over the past 20 years, Canada has accomplished a great deal in tobacco control and has much to be pleased about. Part of the success is the result of particularly effective campaigns led by health advocates, both inside and outside the government, and supported by a large number of impor- tant organizations. Also important were comprehensive tobacco control strategies at all levels of government, including prevention, protection, and cessation initiatives, as well as bold action by many politicians. The achievements are impressive: * Coordinated efforts in the 1980s to increase taxes and so reduce the affordability of tobacco products have contributed to significant declines in smoking: in 1965, 50 percent of Canadians age 15 and older smoked, but by 2001 the rate had dropped to 22 percent. * There is extensive protection from secondhand smoke in workplaces, in public areas, and even in restaurants and bars in some of the larger cities. Canada was the first country to end smoking on international commercial passenger flights, and Canadians played a key role in international efforts to remove secondhand smoke from air travel. * Efforts to inform consumers about the risks of smoking have led to groundbreaking changes in package labeling, including pictorial warn- ings covering half of the surface area of cigarette packages. * Canada has forced the disclosure of additives and many of the toxins in tobacco smoke and has enacted legislation to require changes in tobacco product design. * The impact of the decline in smoking prevalence is beginning to show up in lung cancer rates among Canadian males age 20 and older. Since 2000, the number of new cases has fallen by 100 per year, from 12,200 in 2000 to 12,000 in 2002 (Canadian Cancer Society 2002). 71 72 DAVID SWEANOR AND KEN KYLE It is generally believed that Canada has achieved as much as it has because of particularly favorable circumstances that do not exist in other countries. There is, however, litt]e basis for this assumption. Canada bat- tled the same obstacles-low priority for disease prevention, meager tobacco control resources, and gener al lack of interest in tobacco issues by government and nongovernmental organizal:ions (NGOs)-as faced by most other countries. While the accomplishments are to be applauded, it must be recognized that the success of the tobacco control campaign is also partly explained by the stal-e of afFairs 20 years ago: things were so bad then that significant improvements were not hard to achieve. And Canada still has much to work on. * Tobacco death rates remain very high, and with a rising population, the total number of smokers is about the same as vvhen the tobacco epi- demic was first identified. * Extremely high smoking rates are still found among many segments of Canadian society, especially Aboriginal people. * Too little attention is given to helping smokers quit or otherwise reduce their risks. * Many of the individuals and organizations wilh mandates to reduce disease are still playing only minor roles in the efforts to enact healthy public policies on tobacco control. * Canada still produces more tobacco per capita than the United States. With its mixed picture, the Canadian experience provides important lessons, both for those in Canada who are directly involved and for those deciding what to do-and what not to do-in other countries. A Generation Gap: Before Tobacco Control There are many reasons for Canada's failure to make major tobacco con- trol inroads prior to the 1980s. P'erhaps the rnost significant was that the public health community never managed to institLate policies that would have influenced attitudes about smoking and tobacco use. For their part, the tobacco companies were adept at fostering strong relations with fed- eral and provincial governments and effec:ively forestalling any mea- sures that could have reduced sales. Among the obstacles in the way of tobacco cortrol was the increasing affordability of cigarettes. When adjusted for nflation, the real price of cig- arettes decreased from the end of World War II until 1982. During those years the economy expanded rapidly and personal incomes rose, making tobacco increasingly affordable. The impact was obvious in the numbers. At the beginning of the 1980s, Canada's per capita consumption of tobacco LEGISLATION AND APPLIED ECONOMICS 73 was among the highest of any country on the planet. Canada also had the dubious distinction of having the highest per capita consumption among OECD (Organisation for Economic Co-operation and Development) coun- tries. Smoking among teenagers age 15-19 was extraordinarily high; in 1979, 46 percent of this group reported being smokers, and 42 percent of them already smoked daily (Health Canada 1991). There were no legislated restrictions on tobacco advertising and no mandated warning on tobacco packages until 1989. The only "controls" on advertising and labeling were in a voluntary code of conduct that the tobacco industry constantly violated (NSRA 1986). The tobacco companies appeared to recognize early on that their con- tinued well-being in the face of an avalanche of damning scientific evi- dence was dependent on ensuring that politicians did not move deci- sively to curb tobacco consumption. Unlike the health groups, which at that time were generally absent from political discussions, the tobacco industry made itself heard. It had the ear of government and did its best to control the levers of power. Given that the Canadian tobacco companies have long been owned or controlled by large international companies, this tactic should have come as no surprise. The companies appear to have realized decades ago that if science is not your friend, you had better be sure that governments are. But the success of this strategy in Canada seemed to exceed even its leg- endary accomplishments elsewhere in the world. When, for instance, the U.S. surgeon general released the landmark 1964 report on smoking and health, which said unequivocally that smoking was the cause of an epi- demic of death and disease, the tobacco companies expressed little con- cern. Even as Judy LaMarsh, then minister of national health and wel- fare, stood in the House of Commons asserting that the government would take serious action to confront the problem, the Canadian sub- sidiary of Rothmans made it clear in its annual report that it saw no rea- son for concern (Rothmans 1964). The fact that a former prime minister of the country, and the former leader of the party then in power, was chairman of the board of Rothmans in Canada at the time may have influenced this stance. But the tobacco companies did not reach their position of effective pro- tection from political action against their industry by having just one for- mer prime minister in a position of influence. Several former cabinet min- isters and senior government advisers have taken jobs with tobacco companies. (Indeed, just recently three senators were simultaneously sit- ting in Parliament and on tobacco company boards of directors.) Other "political kingpins in waiting" were appointed to tobacco company posi- tions, and tobacco manufacturers were in politically significant areas such as Montreal and Quebec City. Tobacco farmers in Canada were also a 74 DAVID SWEkNOR AND KEN KYLE powerful political force, using their own governmenit-supported research and their influence on export and rr arketing boards. The 1980s: A Decade of Change A combination of circumstances in tre early 1980s fundamentally changed the face of tobacco control in Canada. In hindsight, this change might look revolutionary, particularly when compared with the inaction of earlier years, but in fact it was a rather slow and sometimes painful evolutionary process. A Lesson in Applied Economics Relatively high inflation in the 1970s caused boti the federal and the provincial governmnents to guard against the erosion of their revenue base by increasing taxes. Both levels of government indexed some taxes to the retail price of specific products, including cigarette,. Each tax increase by one level of government stimulated an increase by the other level. A hike in prices by tobacco companies accelerated this ratcheting. As a result, after 1981 tobacco prices began increasing in real terms for the first time in 30 years. Then something interesting happened: total cig- arette sales starting falling for t:he first time in 30 years. Canadian health advocates got an unexpected lesson in the principles of price elasticity, and they used this information in the political battle surrounding taxa- tion. (See "The Power of Taxation," on page 87.) Mounting Evidence and Interest The mounting scientific evidence of the harm caused by tobacco use solid- ified the interest and support of many individuals whose "time had come." These included tobacco control advocates who had honed their skills in campaigns in some of the larger cities, fighting for smoke-free public spaces and bans on tobacco advertising on public transportation. They included reporters who were becoming interested in tobacco issues and advocates who were learning by trial and error (particularly in Toronto) how to work with the print anrc electronic media. And they even included public servants in the federal health department who, because of personal interest, developed their knowledge aboat tobacco and became serious about reducing the death and disease that iesult from tobacco use. Many of these people had come of age during a time of social activism and had witnessed individuals successh-Elly working together to protest wars, inlfluence environmental policy, push for civil rights, and accom- plish other social goals. As tobaccc procducts becarne recognized as major LEGISLATION AND APPLIED ECONOMICS 75 killers, it was not surprising that many of these people were inspired to take on the cause of tobacco control as another area of social activism. Institutional Response and Coalition Building By far the single most important development in the movement for tobacco control in Canada was the founding of the Non-Smokers' Rights Association (NSRA) in Toronto in 1974 by a small group of social activists. From the beginning, the NSRA combined concern for the rights of non- smokers with an interest in pushing for policy changes that would reduce the overall death toll from tobacco use. Garfield Mahood was hired as the association's first executive director. He had already developed social activist skills as head of an environmental law association and had been successful in working on other social issues. His success in achieving policy breakthroughs attracted the attention of others who shared the view that political activism could save lives. One of them was a young lawyer, David Sweanor, who by 1983 was working full- time alongside Mahood and trying hard to match his feverish intensity. Around this time, a chance incident provided the catalyst for the forma- tion of a tobacco control lobby. In 1985 the federal minister of agriculture proposed the creation of a national Flue-Cured Tobacco Marketing Agency to promote the sale of Canadian tobacco at home and abroad. A number of health groups decided to make presentations to the government to oppose this initiative. Some individuals from these organizations found themselves waiting in the same room for the presentations to begin, and it occurred to them that there might be advantages to cooperation. So, despite being told by senior government officials and members of the media that there was no chance of derailing the marketing board concept, they increased the pres- sure through media advocacy and other measures that made a "done deal" look badly in need of serious reexamination. Soon, the tobacco industry itself became splintered on the issues involved, and the idea of a marketing board fell apart. A lesson learned: seemingly irresistible forces within the tobacco industry could be successfully challenged by effective advocacy. A partnership soon developed between this fast-response advocacy group and the biggest, most prestigious voluntary health charity in the country, the Canadian Cancer Society (CCS). The main function of the CCS up to this point had been to raise funds for medical research through a massive door-to-door campaign held every April. The organization also had a long history of conducting health promotion programs, providing support to cancer patients, and disseminating information on cancer. But by 1986 the CCS decided that it needed to become more involved in advo- cacy. Ken Kyle was hired as director of public issues, and he was instru- mental in building a coalition with the NSRA to work on tobacco control. 76 ]3AVID SWEANOR AND KEN KYLE With a few key committed people taking hold of tie political levers and feeding off each other's knowledge and enithuisiasmt, it did not take long for support for the coalition to grow. Aftei a few yea] s other health groups became involved: first, the Heart anc Stroke Foundat:ion of Canada and, to a lesser extent, the Canadian LuLng Association and the Canadian Medical Association. The Canadian Council on Srnoking and Health (CCSH, now the Canadian Council for Tobacco), vvhiclh was initially run by staff of the three health charities, was part of the coalition' from the start. Other civil society groups such as the United Chu-chl of Canada, labor unions, and women's groups played a smaller but supportive role. Forging Links betweeen Research and Advocacy By the early 1980s a strong body of evidence con:erning the impact of tobacco product pricing on consumption and the danger of secondhand smoke had been developed, and there was clear recognition of the need for serious governmental action in reaction to this evidence and of the effect that advocacy could have in achieving puDlic health objectives. More important, the information from researchers was finding its way to government officials and to health advocates. Academics, often frustrated because research that could save lives was not readily adopted and embodied in government policy, took note of the actions of advocates and sought them out to present useful informaticn. Some of the key data on advertising, taxation, and secondhand smoke made its way to advocates in this fashion. Other researchers and medical specialists, inspired by the publicitv garnered by the advocates' activities, were increasingly recep- tive to their requests for expert assistance. Advocc cy groups such as the NSRA quickly learned that success in public health battles brought more opportunities for progress, including the impetus to build alliances. Working for Policy Change: An Overview Successful advocates learn to take advantage of opportunities as they arise and to respond quickly and creatively. But long-term strategies are important too. As the tobacco control lobby moved toward working at senior levels of government in pursuit of si,nificant policy change and law reform, the "rapid response" approach had to be effectively inte- grated with long-term efforts, and the strategy shifted from short-term battles toward a long-term carnpaign. Hlealth advocates learned to set objectives and use t]-eir relative advantages of information, science, energy, quickness, and dedication :o achLeve them. Of the many policy initiatives in tobacco control proposed over the past 20 years in Canada (see the Appendix to this chapter), those dis- LEGISLATION AND APPLIED ECONOMICS 77 cussed in this section best illustrate successful strategies for policy change on this important issue. These examples may be helpful to others seeking information and inspiration for policy change. The Advertising Tug-of-War At the time the NSRA was formed, the tobacco industry faced no adver- tising restrictions in Canada. Advertisements showed up everywhere and were accepted as part of the landscape. The NSRA recognized that any efforts it or other groups made to help smokers quit were sure to be swamped by massive advertising designed to entice new recruits. As Mahood commented in media interviews at the time, "It is like trying to bail a boat while someone else drills a hole in its bottom." The NSRA therefore began by producing background information on the detrimental effects of tobacco advertising and put together comprehensive arguments for restricting or eliminating tobacco advertisements. In those early days the NSRA did not have the organization or resources to lobby effectively for a nationally legislated end to tobacco advertising, so it set its sights on a smaller target. It launched a campaign to have tobacco advertis- ing removed from the popular Toronto Transit Commission (TTC), the busiest transit system in Canada, which carried over 400 million passengers a year on its subways, streetcars, and buses-and exposed them to continu- ous enticements to smoke cigarettes. The tobacco industry fought hard against the effort to limit its advertising in the TTC and was supported by advertising agencies, billboard companies, and some newspapers and mag- azine publishers, all of which benefited financially from the advertising. In 1979, after a two-year battle supported by a loose coalition of other health groups and backed by Emerson Foote, a living legend in the adver- tising business, the transit authority agreed to drop the advertisements. Those with a vested interest in tobacco advertising were not pleased to have been beaten. A battle had been won, and a war began. What had been learned was that the tobacco industry seemed to have a hard time with constantly moving targets. The tobacco control health lobby built on this lesson with a strategy of using numerous individual efforts to move creatively and methodically toward the long-term goal of ending tobacco product pro- motion. Much of the initial leadership in the campaign for the advertising ban came from Mahood and Sweanor of the NSRA, but there was also a great deal of support from Victor Lachance of the Canadian Council on Smoking and Health and Ken Kyle, whose CCS office in downtown Ottawa became known as the "war room." Pro-public health civil ser- vants like Neil Collishaw also began to have a more receptive audience for the work being done inside the government on tobacco control. As the 78 DA&VID SWEANOR AND KEN KYLE core group of strategists grew, and as other health groups gradually began to focus on tobacco issues, the realm of what might be achievable also expanded. As the campaign moved forward, no one was ever quite sure what would happen next. But the next step came suLdden y. In 1983 the Cana- dian subsidiary of the RJR-Macdortald tobr cco compE ny became the spon- sor of the Canadian Ski Association, allowing the firm to associate ciga- rettes and smoking with skiers who were national heroes. Many of the skiers and the team physicians were appalled. They opposed the decision of their governing body and decided to fight the sponsorship. What could have been a coup for the tobacco industry beca me a rallying point for the health lobby. Health and medical groups that had long paid lip service to public health without getting involved in tobacco control were forced to take positions as the debate heated up. The tobacco promotional contracts with the ski association were leaked, and protests were held. Eventually, the skiers themselves stole the show by refusing to a- cept trophies associ- ated with cigarettes, and they publicly denounced the tobacco company sponsorship. All of this publicity assisted the federal minister of health, who was under pressure on other tobaccc issues, to cut government sub- sidies for sporting bodies that accepted ftinding from the tobacco industry. The industry countered any call for legislation by trumpeting both its own voluntary code on advertising and the voluntar) self-regulation of the advertising industry. Before legislation coLuld reasonably be expected, the health groups had to prove that these existing measures were ineffective. Efforts by a member of the public helped the caus2. Ed Flis, a Canadian citizen, had written several letters to the tobacco campanies during the 1970s in an effort to force the industry to define what it actually meant by the statements in its code of conduct. This was a spontaneous action by a citizen who was simply interested in doing somethirLg about tobacco's toll on society. Flis turned the responses over to the NSRA, and suddenly the health lobby had operational definitions of the code-for example, what the tobacco industry meant by terms such as "immediate vicinity" in ref- erence to the rule about keeping tobacco advertisements away from schools. Armed with this evidence, the health ]obbv/ was able to show that the voluntary codes were totally ineffective. Tn 1984 the NSRA released a list of 250 billboards with tobacco advertisements that were within the pro- scribed distance from schools. Complaints were also filed with the self- regulatory body of the advertising industry. The responses to those com- plaints suggested an unwillingness to rennove a single tobacco ad. Even when the complaints were backed by the expert opinions of epidemiolo- gists, linguists, and lawyers, which left no doubt that the voluntary code had been violated, the initial reaction was to a mend the code to allow the LEGISLATION AND APPLIED ECONOMICS 79 complained-of practice. In 1986 the NSRA prepared a major report, A Cat- alogue of Deception, that documented ongoing violations of virtually every rule in the voluntary code. Some of them were blatant. For example, according to Rule 7, advertising was to be addressed only to adults over 18, but Imperial Tobacco paid to have its brand name and logo on the cen- terfold map of the guidebook to Toronto's "Canada's Wonderland," whose roller coasters and other attractions are designed for children under 18. Rule 1 stated that there would be no advertising or promotion of sponsorships of sports or other popular events through the use of brand names, corporate names, or logos on radio or television, but tobacco logos and brands were constantly seen on televised coverage of sports and other events sponsored by the tobacco industry. In 1986 Health Minister Jake Epp acknowledged that self-regulation of tobacco advertising was ineffective. What really pushed the government into legislative action, however, was a private member's bill sponsored by Lynn McDonald, a member of Parliament from an opposition party and a fierce opponent of smoking. (Private members' bills are sponsored by individual members of Parliament, not by the government, and rarely pass into law.) McDonald's bill, introduced in the House of Commons in October 1986, proposed regulating smoking in federally regulated workplaces and placing tobacco under the Hazardous Products Act. This would mean that tobacco advertising would be prohibited unless exempted by specific pro- visions. Health groups pressured members of Parliament from all parties to support the bill. Eventually, the government decided to draft its own bill banning tobacco advertising, and in 1987 Minister Epp introduced such legislation. The resulting Tobacco Products Control Act was enacted in 1988 and came into force on January 1, 1989. McDonald's bill, entitled the Non-Smokers Health Act, also passed, without the section on adver- tising but with the sections on smoking in public space. (See "Achieving Smoke-Free Space," on page 84.) The goal of moving the government into action had been met, but the war was just heating up. The tobacco industry poured massive sums of money into efforts to derail the legislation. It hired additional lobbyists, including Bill Neville, who was very close to the prime minister and was well connected with virtually the entire federal cabinet. Neville was con- sidered the most powerful lobbyist in the country and was purportedly paid more than any lobbyist in Canada had ever received. Neville's power was undermined by the health groups, which delighted in pointing out his personal connections-this at a time when there was great public interest in eliminating personal influence that sub- verted due process in government. In what many considered to be a mas- ter stroke of the campaign, the health lobby ran a full-page advertisement 80 DAiVI SWEANOR AND KEN KYLE in the national newspaper, the Globe and Mail, showing a picture of the prime minister next to a picture oF Nevillc and accormpanied by an appeal to put the interests of Canadian children ahead of the interests of the tobacco companies. The health lobby also exposed some tobacco industry deceptions, most notably when it showed that an influx of letters to mem- bers of Parliament, designed to look like public opposition to the law, actually consisted of letters composed and printed by the tobacco lobby. Meanwhile, advocates worked hard to build public support for an advertising ban through news conferences, paid newspaper advertise- ments, pamphlets, and the publication of favorable polling results. The CCS organized a campaign to send 35,000 black-bordered postcards (one for every tobacco-related death that year) to members of Parlia- ment. The Canadian Medical Association asked its members to vote against any member of Parliament who did not support the bill. An equally important part of the lobby was the "insicle" strategy, whereby health groups worked with the minister of health and his advisers, offi- cials of the health department, and members of Parliament sitting on the legislative committee reviewing the proposed law. The tobacco industry responded to the passage of the Tobacco Products Control Act with continual efforts to undermine the impact of the regula- tions. And it launched a successful court challenge: in 1995 the Supreme Court of Canada ruled that a total ban on tobacco advertising was uncon- stitutional, effectively invalidatirg important provisions of the act. Health groups reacted immedi ately to this setback by launching a cam- paign for new legislation controlling tobacco advertising and promotion. In November 1996 the health minister, David Dingvwall, introduced a new bill, the Tobacco Act, which sought to outlaw most existing tobacco adver- tising but allowed limited advertising in publications with a mostly adult readership, through direct mail, and in places where young people are prohibited, such as bars. It also incorporated tiie provisions of the Tobacco Sales to Young Persons Act, which had come into force in 1994. That Act raised the minimum age for buying tobacco to age 18, restricted tobacco vending machines to bars and taverns, and set hefty fines for infractions. The new Tobacco Act furthermore provided. for the first government- approved product design standards, package labeling that included health messages, regular industry reports to Healthi Canada on a variety of matters, and restrictions on tobacco sponscrship advertising. The tobacco control lobby, which became known as the National Cam- paign for Action on Tobacco, campaigned heavily. Particularly important this time was the existence within major health organizations of professionals who by now had many years of experience in lobbying for tobacco control legislation. Key campaign participants included the NSRA, the CCS, and Physicians for a Smoke-Free Canada. The Heart and Stroke Foundation of LEGISLATION AND APPLIED ECONOMICS 81 Canada and the Canadian Lung Association lobbied more actively this time. A new and important player was the Coalition quebecoise pour le contr6le du tabac (Quebec Coalition for Tobacco Control). Despite growing support for tobacco control, the campaign still had weaknesses, including a lack of initiative by some health groups, poor coordination within the whole health community, and the usual lack of financial resources (May 1988). The tobacco industry seemed to be always organized and vigorous in its opposition to the campaign, partic- ularly over the issue of tobacco advertising through sponsorship. The industry even established a lobbying group, the Alliance for Sponsorship Freedom, to fight the new law. This group, consisting of organizations receiving tobacco sponsorship money, was funded by the tobacco indus- try and was run through a public relations firm directed by the industry. The industry also engaged in tough direct lobbying, including extensive media advertising. Many of the sports and cultural events sponsored by the tobacco industry were held in the province of Quebec, and the opposition Bloc Quebecois in Parliament did not support the proposed sponsorship restrictions. The minister of health eventually agreed to amendments that delayed the bill by two years. Lobbying activities were then redi- rected to the Senate, where the bill had still to be approved. With a fed- eral election expected shortly, the industry strategy was to force delays so that the bill would not be debated and passed in Parliament before the election. The bill finally passed the Senate on April 16, 1997, less than two weeks before Parliament was dissolved for the election, but in order to get it through caucus, Health Minister Dingwall had to agree to intro- duce a new bill after the election to allow tobacco sponsorship of inter- national automobile races. The new minister of health, Allan Rock, introduced such a bill in June 1998. This Act to Amend the Tobacco Act delayed the implementation date for partial restrictions on tobacco sponsorship from October 1, 2000 to October 1, 2003. Nevertheless, Minister Rock showed an important commitment to tobacco control through a new provision, contained in the bill, to ban all tobacco sponsorship advertising by October 2003. Parlia- ment passed the bill on December 10, 1998. A Picture Worth a Thousand Words: Product Labeling Under Canadian law and the laws of many other countries, manufactur- ers are obligated to warn consumers about the nature and extent of any hazards associated with their products. The warning must be clearly com- municated and must not be negated by collateral efforts on the part of manufacturers. 82 D,AVID SWE XNOR AND KEN KYLE In Canada from 1972 to 1989 the only warning on cigarette packages was one placed voluntarily by the tobacco companies. It appeared in very small type on the side of tobacco packages and read, "Danger to health increases with amount smoked. Avoid inhaling." Health groups had long argued that better information should be providec to consumers, but it was not until the 1980s that a serious campaign fcr legislated messages was launched. After some discussion, the tobacco control lobby agreed to press for large pictorial warning messages and for further information on the inside of tobacco packaging. This particular campaign benefited from one of the most effective combinations of NCOs, the Olfice of the Minister of Health, and federal bureaucrats, working as true partners. It also saw far more use of scientific studies and focus groups tharL in earlier campaigns. A major problem was the lac.k of a clear agreerment on standards for "informed consent." The tobacco industry has consistently claimed that smokers understand smoking may be harmful. Health advocates argued that a much more rigorous stanclard of informed consent with respect to the harm caused by tobacco products was ap propriate and that the level of detail of the information provided should be more like that required of the pharmaceutical and automobile industries. ThE existing warning on cigarette packs conveyed litfle more than a vague notion of the existence of some risk and did nothing to list the specific risks or to quantify them for smokers. Tobacco control advocates aimed to ensure by regulation that worth- while information would be provided by the tobacco companies them- selves as a condition for their selling the'ir products. They began by rais- ing awareness of the need for more information. Consumer surveys were conducted, and past surveys from the federal health department were obtained under freedom of information laws. The results were astound- ing. The surveys revealed that smokers, and young people in the age group most likely to initiate smoking, were unable to name many of the diseases caused by smoking. Most could not even recall that smoking caused heart disease-the single biggest cause of death due to tobacco use (Environics Research Group Ltd. 1990). Health groups were successful in using results from medical research and public opinion surveys to instigate hard-litting media advocacy cam- paigns for legislative reform. Complaints were filed under provincial trade practices legislation accusing tobacco comparies of violating provisions of the laws that prohibit "deception by ornission"-failure to state material facts, so that consurners are deceived or tend to be deceived. There were also coalition news conferences and newspaper articles about the lack of effective and truthful health messages on cigarette packaging, and com- parisons with the countries that did have legislated package warnings. LEGISLATION AND APPLIED ECONOMICS 83 The Tobacco Products Control Act created a legislative framework for regulating package health warnings. Regulations under the act called for cigarette packages to display prominent warnings in contrasting colors covering 20 percent of each of the main panels of both cigarette packs and cartons. The tobacco industry complied, but barely. Suddenly, the "con- trasting colors" turned out to be silver on white, gold on brown, and other combinations that made the wamings hard to read easily. The "main package panel" on cartons was interpreted by the industry as the small- est panel-the ends of the cartons, rather than the sides, obviously con- trary to the intent of the act. The tobacco control coalition turned this short-term setback into a powerful tool for even better package wamings. It exposed to politicians, bureaucrats, and the media the wording of the regulations and the tobacco industry's interpretation of them. Typical responses were anger, laughter, or both. In June 1989 the NSRA released to the public informa- tion it had obtained showing how the tobacco industry had succeeded in weakening the warnings during the regulatory process. The industry may have won a temporary delay against better warnings, but it lost credibil- ity. In January 1990 the coalition celebrated success when the minister of health, Perrin Beatty, announced that the regulations would be revised in July 1991 to require eight rotating messages covering the top 25 percent of the front and back of the packages and printed in black and white-not the package colors. Over the next several months, the issue of the regulations went back and forth. The tobacco control coalition lobbied the new minister of health, Benoit Bouchard, not to implement the new regulations. The NSRA and the Heart and Stroke Foundation of Canada sent pamphlets to the households of the electoral districts of all the members of the cabinet committee that would be deciding on the new (weakened) regulations. A survey by Health Canada found that smokers liked the new proposals for bigger warnings better than the old format. Finally, in 1993 another new minister of health, Mary Collins, pushed the new warnings through the cabinet with an implementation date of September 12, 1994. After all that, in 1995 the Supreme Court of Canada, as part of its rul- ing on the Tobacco Products Control Act (see "The Advertising Tug-of- War," on page 77), narrowly decided in favor of the tobacco industry, say- ing that it was unconstitutional to mandate health warnings unless they were attributed to the government. The tobacco industry's argument was that free speech included the right to silence and that the existence of mandatory but unattributed messages gave the erroneous impression that the tobacco industry was itself giving the warnings. Despite its victory in court, the tobacco industry was in no position to remove the "unconstitutional" messages. Doing so would have raised 84 DAVID SWFANOR AND KEN KYLE serious problems in pending product liability cases and would also have angered legislators. The warnings stayed virtually unchanged for the time being, although the industry made it clear that new legislation would be needed iF the warnings were to exist in the future. WVithin three years, the new Tobacco Act, containing even broader powers to regulate warnings, was passed. In January 1999 Health MirLister Rock released a discussion paper that proposed expanding the warnings to the top 60 percent of the front and back of packages and giving additional information, such as cessation tips and reference to a Website, on the inside of packs. In April the coalition researched and then released to the media and politicians mock-ups of the warnings, whicl-h helpecL greatly with political support. On January 19, 2000, Minister Rock made public 16 pictorial messages that were to appear in rotation on 50 percent of the front and back of packs (see figure 4.1). Some of the pictures were gruesoine, but research from both the federal Department of Health and the CCS showed these warn- ings to be more effective than text-only ones. The final regulations received unanimous approval (a rarity) by both the House of Commons Committee and the House of Commons and were then approved by the cabinet. The Tobacco Products Information Regula- tions became law on June 26, 2000.1 Reaching the goal of providing better information to smokers is an ongoing battle that has taken a lot of hard work. It has been aided, how- ever, by the ability of Canadian health advocates to use research and advocacy to turn defeats into victories, codified in new government pol- icy and legislation. Things that seem to be obstacl2s can in fact open up new opportunities. The key is the ability to see the opportunities when others might see only obstacles. Achieving Smoke-Free Space Protecting the public from secondhand smoke was always considered an important public health goal, given the acute and chronic health problems resulting from exposure. As with all the other major Canadian efforts on tobacco control, it was possible for advocates to determine a long-term goal and then choose appropriate tactics for short-term efforts aimed at eventually allowing Canadians to be free fromn secondhand smoke. By the mid-1970s community-based groups of act, vists such as the NSRA were involved in efforts to get municipal bylaws that would offer protection from secondhand smoke. To begin with, the goals were seemingly modest: 1. Details can be found on Health Canada's Website, . LEGISLATION AND APPLIED ECOI\OMICS 85 Figure 4.1. Examples of Canadian Pictorial Warning Labels for Cigarette Packages N%ER ISSMNT LE TABAGISME PEUT VOUS RENDRE IMPUISSANT La cigarette peut provoquer V'im- puissance sexuelle car elle reduit la circulation du sang dans le p6nis. Cela peut vous rendre incapable d'avoir une erection. Sante Canada DON'T X (eALETABAISON PETSOU WARNING: Second-hand smoke contains carbon monoxide, ammonia, f formaldehyde, benzo[adpyrene and nitrosamines. These chemicals can harm your children. Health Canada Source: Health Canada. Reprinted by permission. prohibiting smoking in elevators, food stores, and other confined spaces. The groups recognized that the most dramatic efforts, such as pushing for smoking bans in public areas, were the least lkely to be effective. Several cities, including Victoria, Vancouver, Edmonton, Toronto, and Ottawa, passed the more limited laws. As the public grew used to them, amend- ments were gradually introduced to broaden their scope. 86 DAVID SWEANOR AND KEN KYLE Efforts moved to the national level in 1986 when, as described above, Lynn McDonald introduced the Non-Smokers Health Act in the House of Commons. This private member's bill was designec to ensure protection from secondhand smoke in federally regulated workplaces. Although it was given little chance of success, it gathered growing support and man- aged to dodge various efforts to have it killed. Much of the credit for the eventual enactment of the bill goes to Cyn- thia Callard, now executive director of Phy sicians for a Smoke-Free Canada, who was at the time an assistant to TMcDcnald. She brought to the effort a passion for public health, kncwledge of the Canadian parlia- mentary system, and an ability to get others involved. McDonald's bill provided the catalyst for the government to draft its own bill limiting tobacco advertising, the Tobacco Products Control Act (see "The Adver- tising Tug-of-War," on page 77). The two bills ended up traveling together through the legislative process. Every effort by the tobacco industry to stop them was countered, and each bill helped the other move forward. On May 31, 1988, both bills were passed by the House of Commons in an extraordinary vote in which members voted as individuals rather than along party lines. The power of the tobacco lobby and its advocacy groups, and its questionable claims of little harm from secondhand smoke, had been beaten back. The Non-Smokers' Health Act essentially gave all federally regulated workers (about 10 percent of Canada's workforce) the right to a smoke- free workplace. Flight attendants, passenger train workers, and intercity bus drivers fell under the law and received the right to be free from ciga- rette smoke. Naturally, implementation wvas a challenge. Many of the companies involved, including the airlines, claimed that the law would put them out of business. The airlines were particularly effective in obtaining extensions of the deadline due to concerns about competition on international routes. But the health lobby pressed forward. The flight length for smoke- free aircraft was gradually increased until all flights except those to Asia were covered, and then that exemption was also eliminated. Canada became the first country to have all flights of its airlines smoke-free. As it turned out, not only was there no competitive c.isadvantage; the air- lines found that the clean air policy attrac-ted business from competitors. In only a short time other airlines recognized the advantages of smoke- free travel, and within a few years virtually all the major air carriers were smoke-free. Airlines were not the only battleground ior the implementation of the new law. At one point the government nearly passed a regulation that would have exempted intercity buses from ihe nonsmoking law. Rather than attack the government plan, the NSRA and the CCS LEGISLATION AND APPLIED ECONOMICS 87 approached the bus companies directly. It was pointed out that other forms of transportation were going smoke-free and that the buses would suffer from a "lower-class" image if they continued to allow smoking. This happened precisely when the industry was trying to move up-market. The result was that the bus companies demanded to be designated smoke-free, proving that allies can often be found when they are creatively sought. The federal law led the way, but provincial regulations were not far behind, as smoke-free spaces became the norm. Meanwhile, the fight for further protection from secondhand smoke moved to restaurants and bars, previously thought to be off-limits to clean air policies. In many cases this move was voluntary, but to give a consistent level of protection, legislation was needed. As with earlier efforts to clear the air, the first steps were taken at the municipal level. By 2002 most of Canada's largest cities either had smoke-free bars and restaurants or were in the process of making them so. It has been a long journey from the days of fighting to get smoking out of food stores and elevators, but there was never doubt about the eventual achievement of the broader goal. The Power of Taxation The affordability of tobacco products has repeatedly proved to be the single biggest factor in determining per capita consumption (World Bank 1999). As with virtually all other products, as prices increase, con- sumption decreases. Yet, as in other countries, Canadian health advo- cates were rather slow in turning this fundamental law of economics into a public health tool. In 1983 it began to be clear that price was a very powerful factor in cig- arette sales. As a result of the indexation of taxes, cigarette prices began to show a sustained increase in real terms for the first time in over 30 years. There was an immediate impact: total cigarette sales began to fall-some- thing the country had not previously experienced. Some very good analyses of the price elasticity of tobacco products had already been done, primarily in the United States and the United King- dom, and they had been replicated for Canada and disseminated by Neil Collishaw at the federal health department. But although the tax structure in place was a huge benefit to public health, it was under attack by the tobacco industry, as well as alcohol companies, which had been subject to the same escalating taxes. Under pressure from these interests, the federal government set up a committee to review the taxes and recommend changes. The members of the committee came from the tobacco and alco- hol industries; not one representative of health groups was invited to attend, nor did any health groups (except for one that sent a single letter) 88 DAVID SWEANOR AND KEN KYLE make any submissions to the commi:tee or to the government. The result was that the indexed tax increases were repealed. But once again, a defeat paved the way for a much greater victory. In 1984 the Progressive Conservative Party was electec. to form the govern- ment. After an advocacy campaign led by David Swveanor of the NSRA, the new finance minister, Michael Wilson, raised tobacco taxes by a penny a cigarette in 1985. Consumptior, fell once more, and health advocates began to understand the relationship between prices and consumption. Under the NSRA's leadership, an organized effort began to take shape to press for greatly increased tobacco taxes (\TSRA 1992'). Once again, health advocates set a long-range geal and started work- ing on the building blocks necessary to reach it. In the early stages the efforts were relatively simple. Letters and sub missions were sent to gov- ernments, presenting both the health justification for tobacco tax increases and the sales and revenue implications, using the be ,t available estimates of price elasticity for cigarettes. In some cases meet:ings were held with civil servants and political advisers involved n crafting budgets. These efforts began to show results. Government officials were often very pleased to have health advocates talk about tobacco taxes, occasionally mentioning how for years they had been lobbied by the tobacco industry and had always wanted to get the perspective of "tl- e other side." But significant obstacles stood in the way of imposing higher tobacco taxes. Perhaps the biggest was that posed by Ontario. The province was, after North Carolina and Kentucky, the largest grower of tobacco in North America, and its tobacco taxes were among the lowcst of any province. A new provincial government had just been elected, and the minister of finance was a long-serving politician from the "tobacco belt." He was on record as opposing any tobacco tax increase because of the impact on tobacco farmers, and one of the first acts of his government was to rescind a pending tobacco tax hike. Ontario represented well over 35 percent of the nation's population, and its low tobacco prices acted as a ceiling that kept neighboring provinces' taxes lower. ft was critical that the "Ontario obstacle" be removed. To that end, the NSRA conducted an analys;s of the impact of rescind- ing the previously announced tobacco tax increase. Particular attention was paid to tobacco growers. Tobacco lea f is an exceedingly tiny part of the price of manufactured cigarettes-a fact often overlooked when con- cern for tobacco farmers is used as a justification for not increasing taxes. In late October 1985 the NSRA put together figures showing that the government was forgoing revenues of over 130 million Canadian dollars (CA$), equivalent to US$95 million, in ordcr to maintain higher sales that amounted to the average production of only a dozen farms (Sweanor 1985). LEGISLATION AND APPLIED ECONOMICS 89 On November 1, 1985, the NSRA held a press conference at the Ontario Legislature denouncing the tax decision as both a blow to public health and possibly the least cost-effective farm support scheme that any gov- ernment had ever devised. The media were not used to hearing economic arguments from health advocates. Some of the reporters called govern- ment finance officials for verification and were told that the NSRA analy- sis was correct. The next day, both the analysis and a statement by a senior civil servant agreeing with it were published in the Globe and Mail. Momentum was building. Soon there was a coalition, including the NSRA and health charities, that supported significant tobacco tax increases in Ontario and recommended that some of the revenue raised be directed to helping displaced tobacco farmers. Despite his early pro- tobacco leanings, which had earned him the moniker "Tobacco Bob," the finance minister delivered the two biggest tobacco tax increases in Ontario's history during his five years in office. He also funded realistic efforts to help tobacco growers diversify. While this was going on in Ontario, complementary actions were occur- ring in all of the other provinces and at the federal level. Ongoing meetings with government officials, political advisers, and cabinet ministers were held. Tobacco industry submissions were obtained (usually under freedom of information laws) and critiqued. The CCS, the Canadian Medical Asso- ciation, and the Canadian Council on Smoking and Health were making effective use of their staffs and volunteers in various efforts across the country to bring forward tax submissions and meet with decisionmakers. The submissions were primarily produced by the NSRA, which had devel- oped expertise in this area. By the late 1980s provincial governments were calling the NSRA for information on tobacco taxes and for recommenda- tions on how big the tax increases should be. The federal government increased its tobacco taxes by more than 6 cents a cigarette between 1985 and 1991 as the "tobacco tax project" geared up, and provincial governments roughly matched this level of increase. As expected, consumption fell dramatically. According to Health Canada and Statistics Canada figures, reported domestic sales dropped by 40 percent between 1982 and 1992. Health Canada prevalence surveys also showed that teenagers, who had long been shown to be price-sensitive, achieved a per capita decline of 60 percent. Whereas the 1979 survey showed that 42 percent of 15- to 19-year-olds were daily smokers, by 1991 only 16 per- cent were (Statistics Canada n.d.). In response to the tax increases, the tobacco industry fought back. This time, it focused on the issue of cigarette smuggling. At the time, cigarette prices in the United States were less than half those in Canada. The tobacco industry argued that if the price differential remained, a smug- gling problem would soon develop. 90 DAVID SWEANOR AND KEN KYLE There was little evidence in the late 1980s and early 1990s to back up this industry position. Canadians were smoking di fferent brands and different tobacco blends than Americans, and sales of U.S. brands in Canada (both legal and otherwise) were decliring. But in the early 1990s "exports" of Canadian cigarettes to the United States surged. A. the same time, there seemed to be an increase in smuggled cigarettes coming into Canada. Interestingly, these smuggled cigEarettes vwere Canaclian blends and Cana- dian brands-the very ones that we -e being "exported" in the first place. The tobacco companies and their allies meanwhile claimed that smug- gling was a huge threat to the courntry and urged governments to lower tobacco taxes as the only way to deal with the scourge. Cigarette retailers joined in the effort to secure a Lax rollEack in hopes of reclaiming lost sales. In February 1994 the new Liberal government responded by drasti- cally reducing tobacco taxes. As figures 4.2 and 4.3 suggest, there was some increase in consumption, especially armong young Canadians. The tax rollbacks lost much of the ground that had been gained since 1982 and poisoned relations between tobacco control advocates and government officials for several years. The smuggling problem went away as if someone had suddenly turned off a tap (NSRA 1994). There was considerable controversy about the actual level of smuggling and hen-ce of total consumption. Many people argued that the high taxes had "caused" smuggling. They cer- tainly provided an incentive to smuggle, but seeing them as the "cause" of smuggling is like describing an iceberg as a chlink of ice sticking up from the ocean-true as far as it goes, but niot the full story at all. The key question is where the smuggled cigarettes were coming from-who was supplying the illegal market? Most of the smuLggled cigarettes were manufactured in Canada and expo-ted to the Unit2d States, where there was little demand for Canadian brands. Did the exporters think their cigarettes would stay in the United States, or did they know that they would be smuggled back into Canada? Eventually, one of the tobacco companies entered a guilty plea in a U.S. court, admitting to having knowingly played a role in the smuggling. A. crim[nal investigation was instituted in Canada. Recently, taxes have again been on the increase and now exceed early 1994 levels in all provinces. With every i-ncrease, though, consumption declines. These tax and consumption trends continue to be monitored by the NSRA, the CCS, and Physicians for E Smoke-Fiee Canada. Working through the Courtsfor Policy Change Lawsuits have been used effectively in Canada in the long-term campaign for tobacco control. Using the cou -t system to effect policy change is a LEGISLATION AND APPLIED ECONOMICS 91 Figure 4.2. Cigarette Consumption and Real Cigarette Prices, Canada, 1949-98 Per capita consumption, legal sales only -.-- Real price of 200 cigarettes (1992 dollars) .i $50 ---- Per capita consumption, including estimated contraband 4,500 CL U $40 - 4 g $25 3,500 0 N $10 2,000 Q 2$20 Cu o.~~~~~~~~~~~~~~~~~~~~~~~~~C 1- ,500 C n $15 cmj $10 00 .~$5 - C c 1949 1953 1957 1961 1965 1969 1973 1977 1981 1985 1989 1993 1997 Note: Real prices are calculated from the consumer price index. In high-smuggling years the effective price was lower because smuggled cigarettes evade taxes and are sold at prices below the retail prices of legally sold cigarettes. Consumption data include the highest credible estimate of contraband sales. Cigarettes include fine-cut tobacco equivalents (1 g). Source: NSRA data. lengthy process and is sometimes unpredictable, but the ultimate positive results can be large and durable. In a few provinces laws have been used to bring the tobacco industry to court. For example, in 1997 the legislature of British Columbia passed the Tobacco Damages Recovery Act to assist the provincial government in a lawsuit to recover from the industry costs related to provision of pub- licly funded hospital and physician services. (The act's title was later changed to the Tobacco Damages and Health Care Costs Recovery Act.) The provincial government then filed an action in the British Columbia Supreme Court against the tobacco industry. The industry challenged the constitutionality of the legislation, and in February 2000 the court ruled the act invalid but upheld some of its major principles. The legislature again amended the act, and the government has launched a new lawsuit. Ontario passed similar legislation in 1999: the Ministry of Health and Long-Term Care Statute Law Amendment Act. In March 2000 the provincial 92 ]CIAVID SWEANOR AND KEN KYLE Figure 4.3. Smoking Prevalence amonlg Teenagers Age 15-19, Regular Smokers, Canada, 1977--94 -a-- Female 50 . +-Male 45 40 X.? 35 en 30 25 20 0 0 1 0 0 . . . . . . 1977 1979 1981 1983 1985 1987 19E9 1991 1993 1995 Source: NSRA, using Statistics Canada catalogues 91-032, 91-512, and 91-213; labor force survey data from Statistics Canada (1991); and 'Su-vey oni Canada," cycle 3, 1994. government filed a lawsuit against the industry in U. S. Federal Court under the Racketeer Influenced and Corrupt Organizations (RICO) Act, but in August 2000 the case was dismissed on the grounds that the provincial gov- ernment could not sue in a U.S. court. The provincial government is plan- ning an appeal. Newfoundland has also recently passed a Tobacco Health Care Costs Recovery Act, originally introduced in December 2000. Lessons Learrned There were, of course, many other battles on other cspects of tobacco con- trol, and there was much more to each of the exarmples cited above than can be adequately conveyed in a few pages. Yet the same lessons seem to shine through. A small group of dedicated people truly can-and did- change the world. They had to set long-terrn goals and to work realisti- cally toward achieving them. They had to look for allies in the govern- ment and beyond, to work with the media, and to take advantage of opportunities as they arose. They had to use research-both their own and from other organizations-to obtain the inforrnation they needed in LEGISLATION AND APPLIED ECONOMICS 93 good time and provide it to decisionmakers and the public. They had to be creative, and, for long-term success, they had to have enough sense of camaraderie and accomplishment to want to stay in the fight. Some other general lessons learned along the way may inform others in their own efforts. Dealing with an Oligopoly The tobacco industry in Canada, as in so many other countries, is composed of a very small number of companies that control roughly 99 percent of the market. A single company, Imperial Tobacco Ltd., holds roughly two-thirds of the entire market. Profit margins have traditionally been huge. This gives the tobacco industry a great interest in opposing measures that threaten to curtail the market plus virtually unlimited financial resources for backing its opposition to measures not to its liking. In more competitive markets, the expenditure of millions of dollars on lawyers to fight government leg- islation would lower a company's profits and make it uncompetitive in the long run. But in the case of the oligopolistic cigarette market, as long as the companies are all in it together, the cost of litigation, lobbyists, "science" to order, and so on is not a problem. The companies can raise prices to cover the costs and continue to realize enormous profits. Globally, the industry is consolidating rather than becoming more competitive. Countries with competition laws that have been used to combat concentrations or lack of price competition in other industries have not so far opposed consolidation of cigarette companies or tried to curb the power of the cigarette cartels. The companies remain economi- cally powerful and use their resources to build political influence, creat- ing a formidable barrier to tobacco control policy. This makes trans- parency and public debate on proposed legislation extremely important. Understanding the Nature of Effective Legislation Canadian groups spent much time in the late 1980s and 1990s going from one legislative battle to the next. It began to appear more sensible to simply regulate tobacco products like other drugs or hazardous prod- ucts. The tobacco industry benefited from an approach to regulation that essentially said they could do anything that was not specifically forbid- den. Given the nature of the product and the legislative precedents for other products, it made more sense to reverse the onus. Tobacco prod- ucts and the marketing and labeling of these products could be like pharmaceuticals-banned except to the extent that a regulatory author- ity gives specific permission for specified actions. This was the philoso- phy behind the new Tobacco Act. 94 DAVID SWE/NOR AND KEN KYLE Thinking Globally,-Acting Locally Canada's total consumption of tobacco prcducts repr2sents less than 1 per- cent of global sales. Although significanit progres; has been made in Canada, it is only of global significance when it helps efforts in other coun- tries. Similarly, successful measures in other countries can assist efforts to achieve breakthroughs in Canada Much of what has happened in Canada has aczordingly been done with an eye to global relevance. Many of the key Canadian advocates of tobacco control have long been involved in working at a global level, and much of what has been accompLshed in Canada has been immediately communicated in various ways to colleagues elsewhere in the hope of aiding their work. But the learning goes both ways. Interaction at a global level has greatly assisted Canadian efforts. Not only were Canadians able to learn from the tobacco control initiatives of other countries, but also success in exporting Canadian breakthroughs to other countries reinforced the momentum for continued progress within Canada. For decisionrnakers in Canada the moves elsewhere to smoke-free airlines, bigger health warnings on packages, and higher taxes-often with direct connections to what had already hap- pened in Canada-reinforced the sense that Canada was on the right track. Finding Allies One of the most intriguing lessons was that although some allies came from expected sources, such as the CCS, other health and medical orga- nizations were simply not comfortable putting much time, personnel, or resources into tobacco control. Indeed, many organizations that repre- sented health professionals who daily saw .he devastation caused by tobacco, and many charities dedicated to battling illnesses caused to a large degree by tobacco use, were often only peri heral players in the major tobacco control campaigns. But other strong allies were constantly being found. Some were dedi- cated individuals who could rally the support of various constituencies. Individual volunteers with health charities anct medical associations were often pivotal in the campaigns. Tliere were also some tremendously engaged ministers of health-politicians wvho, once they knew they could truly make a difference, literally r isked their political futures in efforts to put through public health measures. More than one minister threatened resignation if an equivocating cabinet sided with the tobacco lobby at crit- ical moments in the battles for legislation. Assistants to politicians, and part-icularly aides to ministers, were key allies. Usually young, energetic, and idealistic, marLy of them were com- mitted to ensuring that health rrLeasures macle it tlhrough the labyrinth- LEGISLATION AND APPLIED ECONOMICS 95 like structure of government. They were often the key driving force in get- ting precedents set, and they seldom received any public acknowledg- ment of their tremendous efforts. Doing a Lot on a Limited Budget Health advocates in Canada seldom had much by way of financial resources. Most campaigns were run on energy and creativity in place of money. Money was always an area in which the tobacco lobby had a huge edge. The health lobby, however, had a relative advantage in its ability to move quickly and creatively. Many of the major battles cost little or nothing. Volunteers played a huge role in many of the tobacco control victories. Persuading a senior CCS vol- unteer or prominent physician to speak to a politician was free. Getting information to millions of Canadians through effective media work cost lit- tle or nothing. Finding tobacco billboards next to schools simply meant having someone willing to drive around cities and note the location of the signs. Preparing detailed submissions on tobacco taxes often required no more than having someone willing to crunch numbers and present the find- ings in ways designed to get the attention of a desired audience. Money helps. But having a lot of money is not a prerequisite for success. Canadian advocates could joke in the 1980s that they were "changing the world on five dollars a day." The formula for success in Canada has involved dedicated action by a variety of actors: strong commitment by municipal, provincial, territorial and federal governments, both politicians and civil servants; good research; and leadership by NGOs that added spe- cialized political and economic research to existing medical and public health research and used it to target public policy and conduct media advocacy campaigns. With the use of new and existing alliances and of grassroots mobilization, these activities were effective with more or less all national political parties. Political ideology played only a minor role in these events, and the tobacco control coalition wisely was usually careful to maintain a nonpartisan stance. To sum up, it is not a stretch to say that a few individuals in the coali- tion, working with politicians, the federal bureaucracy, and the media, have potentially saved thousands of lives. This is one of the most impor- tant public health stories in Canada's history. Appendix: Key Dates in Tobacco Control in Canada 1908: Canadian Parliament passes the Tobacco Restraint Act, which pro- hibits the sale of tobacco products to persons less than 16 years of age. 1951: National Cancer Institute of Canada says there is a possible link between smoking and cancer. 96 DAVID SWEANOR AND KEN KYLE 1963: Federal Health Minister Judy LaMarsh states that smoking causes lung cancer. 1963: Tobacco lobby (Canadian Tobacco M/anufacturers' Council) is established. 1968: Health Minister John Munroe condemns the E dvertising of tobacco products. 1974: Non-Smokers' Rights Association is establishe,d. 1986: Canadian Cancer Society embarks on public policy advocacy for tobacco control. 1988: Parliament passes Tobacco Products Control Act and the Non- Smokers Health Act. 1991: Federal tobacco taxes are increased by CA$6 (US$5) a carton. 1993: Parliament passes Tobacco Sales to Young Persons Act. 1994: Federal government cuts tobacco taxes in half. 1995: Supreme Court of Canada rules ma; or portions of Tobacco Products Control Act unconstitutional. 1997: Parliament passes the Tobacco Act. 2000: New pictorial health warrLings become law. References Canadian Cancer Society (CCS), National Cancer Institute of Canada, Statistics Canada, Provincial/Territorial Cancer Regist-ies, and Health Canada. 2001. Canadian Cancer Statistics, 2001. Toronto. Available at *-http://www.cancer.ca>. 2002. Canadian Cancer Statistics, 2002. oronto. Available at . Environics Research Group Ltd. 1990. "Awareness of H-Iealth Hazards Due to Smoking." December. Prepared for the Canadian C'ouncil on Smoking and Health. Ottawa. Globe and Mail. 1985. "Ontario to Lose $130 Million in Cigarette Taxes." November 2. Health Canada. 1991. "Canadians and Smoking: An Update." Cat. no. H39-214/1991E. Health Canada, Minister of Supply and Services, Ottawa. May, N. 1988. "Health versus Big Tobacco: A Review of the Campaign to Pass Bill C-71, the Tobacco Act." Canadian Cancer Society, Toronto. NSRA (Non-Smokers' Rights Association). 1986. A Catalogue of Deception. Toronto. 1992. "The Canadian Tobacco Tax Project." Toronto. 1994. "The Smuggling of Tobacco Products: LessorL from Canada." Toronto. Rothmans. 1964. "Annual Report." Rothmans of Pall Mall Canada Limited, Toronto. Statistics Canada. 1991. "Canadians and Smoking: An Update." Health and Welfare Canada. Ottawa. n.d. Cat. nos. 32-022-XIB 91-002, 91-512, 91-213. Ottawa. 1994. "Survey on Canada." Ottawa. Sweanor, D. 1985. "A Review of Tobacco Taxation L'olicies in the Current Ontario Budget." NSRA, Toronto. World Bank. 1999. Curbing the Epidemic: Governmei- ts and the Economics of Tobacco Control. Development in Practice series. 'Was]-ingto n, D.C. 5 Democracy and Health: Tobacco Control in Poland Witold ZatoMski At the end of the 1980s, Poland had the highest cigarette consumption in the world. Polish men, in particular, had been heavy smokers for years. Their addiction had made cancers common and lives short (figure 5.1). By 1990, the odds that a 15-year-old Polish boy would live to the age of 60 were lower than for his peers in most other countries in the world, includ- ing India and China (Murray and Lopez 1994). The World Health Organi- zation (WHO) estimated that almost half of the premature deaths among Polish men were caused by inhaling tobacco smoke (Peto and others 1992). Over half of the burden of noncommunicable disease among Polish men was smoking related. The medical community in Poland began to raise the alarm in the 1980s, when it became clear that the incidence of lung cancer in Poland was higher than almost anywhere else in Europe except Hungary (Zatoniski and others 1996). The health, economic, and social costs of smoking spurred Polish doctors and health advocates to look for ways of reversing the advancing health catastrophe. Tobacco Consumption in Poland: Historical Background Cigarette smoking accounts for nearly 100 percent of tobacco consumption in Poland. In the 1920s and 1930s tobacco consumption remained stable at a relatively low level of about 500 to 700 cigarettes per person per year. After World War II, the figure rose steadily until the late 1970s, when it was one of the highest in the world, at well over 3,500 cigarettes per person per year (Zatoiiski and Becker 1988). The economic crisis of the late 1970s lim- ited access to cigarettes, and tobacco consumption stopped rising. The earliest studies on the prevalence of smoking in different socio- demographic groups date from 1974. The Maria Sklodowska-Curie Memo- rial Cancer Centre and Institute of Oncology (referred to in this chapter as the Cancer Centre and Institute) in Warsaw has conducted such studies almost every year since 1980. The studies revealed that in the mid-1970s, 97 98 WITOLD ZATOKSKI Figure 5.1. Probability of Dying of Vlarious Causes for Men Age 15-59, by Region, 1990 Injuries * Noncommunicable diseases D Communicable diseases _2 F ~~Established Mvar6e Econornies l l . l E W l ~~~~~Poland .1 .l' =I: lCh na I_ | Latin America and the Caribbean l l I niir w _ Other Asia and slands _ iniirz Middle Eastern Cresscnt _ =X1 1 ~~~~~~~~~lidia i _____ _____ _____ _____ ___________________ Sub-Saharan Africa 0 5 10 15 20 25 30 35 40 Percent Soutrce: Adapted from Murray and Lopez (1994). 65 to 75 percent of Polish men belween ages 20 and 60 smoked every day, and less than 10 percent of men in some age groups said that they had never smoked (Zatoiiski and Przewozniak 1992a, 1999). Smokers rarely quit: only a small proportion of men said they were ex-smokers. Smoking was a social norm in the adult male population. Far ifewer women smoked than men, but the figures for women aLso rose consistently for all age groups. From 1974 to 1982, smoking prevalence among adult women increased from 20 to 30 percent--which was the highest level ever recorded (Zatoniski and Przewozniak 1992a). Some o F the increase in smok- ing prevalence was a result of the way that cigarettes were rationed from 1981 to 1983: all employees received a quota of cigarettes whether or not they smoked. The result was an increase of I million in the number of smokers between 1981 and 1982, even though the number of cigarettes available on the market was static. Throughout the 1980s, smoking prevalence among men continued to be very high, although minor decreases were noted in all age groups and more people in the youngest group began reporhtng that tl ey had never smoked. This change may have been due to limited availability of cigarettes. The percentage of women smoking remained at about 30 percent, but consider- DEMOCRACY AND HEALTH: TOBACCO CONTROL IN POLAND 99 able differences appeared across age groups. Smoking prevalence among the oldest women was 5 to 10 percent, compared with nearly 50 percent among the youngest adult women (Zatonski and Przewozniak 1999). Tobacco-Related Diseases The growth of tobacco consumption in Poland after World War II led to an increase in morbidity and mortality caused by diseases and disorders related to inhalation of cigarette smoke. Lung cancer is a good indicator of health damage caused by smoking because it is found almost exclu- sively among tobacco smokers (Tyczyiiski and others 2000). After World War II, lung cancer mortality in Poland increased for men and women in all age groups. In the mid-1960s it was relatively low compared with rates in the United Kingdom and the United States (figure 5.2). In middle-aged men, however, lung cancer mortality increased rapidly. By the late 1970s it exceeded rates in both the United Kingdom and the United States (fig- ure 5.3), and it continued to climb in Poland well after it had dropped in the other two countries (Zatoriski 1995). The health consequences of inhal- ing cigarette smoke were less marked for women because of lower smok- ing prevalence (Peto and others 1994). By the early 1980s the incidence of lung cancer among middle-aged Pol- ish men was among the highest in the world and was significantly higher than it had ever been in any high-risk Western European country (for example, the United Kingdom or Finland). Figures for other cancers related to the inhalation of cigarette smoke, such as laryngeal and oral can- cer, had also reached their highest levels by that time. Six of the 10 most frequent cancer sites in men were tobacco related (Zatoriski and Tyczyriski 1997). Epidemiological estimates indicate that 58 percent of malignant tumors in middle-aged men were caused by cigarette smoking. Similarly, studies showed that 42 percent of cardiovascular deaths and 71 percent of respiratory disease mortality among middle-aged men were smoking related (Peto and others 1994). Tobacco Control in the 1980s Unlike the case in most developed and developing countries, information about tobacco-related health damage was censored in Poland. Tobacco and cigarette production was an important source of government rev- enue. Health and the factors determining health were given little promi- nence in the media, which were controlled by the totalitarian regime. Sci- entific reports on health damage from tobacco smoke that received publicity in Western countries did not reach Poles. Public awareness of the dangers of tobacco use remained low. 100 WITOLD ZATONSKI Figure 5.2. Mortality Trends for Lung Cancer, All Age Groups, Men and Women, Poland, the United. Kingdomn, and the United States, 1959--99 Men 80 70 3 60 , f ' 0. 00 0 40 cz 30 X - z - United Kingdom Cu X 20 - F *--- ~~~~~ ~ ~~Poland_ 0 1959 1964 1969 1974 1979 1984 1989 1994 1999 Women 25 -.--United States 0 i: ~ ^- Poland CoL 20 0. 15 X. 10 05 1959 1964 1969 1974 197S 1984 1989 1994 1999 Soturce: Cancer Centre and Institute, WAarsaw, using data from Peto and others (1994) and Central Statistical Office of Poland (various years). DEMOCRACY AND HEALTH: TOBACCO CONTROL IN POLAND 101 Figure 5.3. Mortality Trends for Lung Cancer, Men Age 45-64, Poland, the United Kingdom, and the United States, 1959-99 250 United Kingdom 250 - _ + United States ---tPoland 200 05 100 50 0 I T I 1959 1964 1969 1974 1979 1984 1989 1994 1999 Source: Cancer Centre and Institute, Warsaw, using data from Peto and others (1994) and Central Statistical Office of Poland (various years). Existing tobacco control regulations were paper tigers-they looked strong on paper but were ineffective because of lack of enforcement. For example, a 1974 law forbidding smoking in health centers was never enforced. This was a problem of considerable importance because ciga- rette smoking by physicians in health centers became widespread. In some medical specialties the percentage of doctors who smoked was higher than among the general population. In fact, physician smokers outnumbered all Polish women smokers. New Information about Tobacco The growing catastrophe in adult health was first described in the early 1980s, as the voice of Polish civil society, symbolized by the democratic Soli- darity movement, was gaining influence. As Polish society gradually became more open, more information on health issues was aired in the media. The 1980s saw the first publication of general information and scientific papers documenting tobacco smoking as the key causal factor in the growing cancer epidemic and in premature mortality among young and middle-aged adults (see, for example, Zatoriski, Gottesman, and Przewozniak 1987). 102 WITOLD ZATONSKI The political changes of the 1980s made possible the establishment of public organizations intent on inmproving the healtlh of Poles by reducing the popularity of smoking. Several groups associated with the medical pro- fession launched scientific studies, as well as activities that included devel- oping tobacco control programs, educatirg the pub]ic, organizing debates and scientific conferences, and estab]ishing linkcs with international organi- zations. Through those international contacts, especially with the Interna- tional Union against Cancer (UICC) and the WHIO, Polish health advocates became involved in actions to reduce tobacco consuinption. In the early 1980s the Cancer Centre and Institute undertook system- atic studies on the health consequences of cigarette smoking in Poland. Within a framework of international cooperation, investigators used WHO standard methodologies and definitions to document the relation- ship between smoking and the rapidly growing cancer epidemic. From these studies came the scientific basis for the iirst Polish report on smok- ing and health in Poland (ZatoTiski and Przewozniak 1992a, 1992b). Also in the early 1980s, the medical and scientific communities orga- nized the first scientific conferences and workshops, in collaboration with the UICC and with Finnish medical organizations. These gatherings con- tributed to the growing understanding of the magnitude of smoking- related disease in Poland. They also highlighted the potential for effective interventions. During this period, health experts from Finland (Matti Rimpela) and the United Kingdom (Richard Peto and Michael Wood) helped develop the first research and intervention programs. While this scientific and public healtlh activity was going on, tobacco control advocates began communicating their mess age to the public with the help of the media. They also organized Poland's first participation in World No Tobacco Day, in collaboration with the WHO. Advances Despite Constrairits These efforts did not always receive government support and were some- times criticized by government cfficials. [n the early 1980s the prime min- ister's legislative council rejected a bill, prepa red uA ith the help of experts from Finland and the UICC, that vwould have established regulations to help reduce the health consequences of smoking. Officially, the bill was dropped on technicalities, but the actual reason was the perceived threat it posed to the country's weak economy. The tobEcco sector was a gov- ernment monopoly, and it was feared that a reduction in smoking would affect government revenues. Similarly, attempts to alert the public, whether at home or abroad, to Poland's poor health conditions could be only partly successful. Free media did not exist in Poland, and the gover-nmen-t had little interest in DEMOCRACY AND HEALTH: TOBACCO CONTROL IN POLAND 103 health matters. In a nondemocratic system, health-related activities could be implemented only to a limited extent unless they were supported by the government. Despite limited government support, tobacco control advocates made the 1980s an important period of preparing scientific assessments, com- piling databases, training experts, establishing links with international organizations, and developing intervention programs. They took advan- tage of their opportunities and achieved four important things: * The creation of a body of independent experts * The establishment of the Polish Anti-Tobacco Society, an organization of health advocates * The initiation of scientific research to document, for the first time, the role of tobacco in the adult health crisis in Poland * The initiation of collaboration with scientific, social, and international organizations abroad. The Impact of Democracy and a Free Market With the breakdown of the communist system, Polish tobacco control advocates faced new challenges and opportunities. Regulations govern- ing economic activity were changed to make way for a free market in 1988 and 1989. The introduction of a market economy seemed likely to increase tobacco use, with grim consequences for public health. The production and sale of cigarettes, which had been entirely controlled by the govern- ment, was one of the first economic sectors to be privatized. Within a few years, the Polish tobacco companies were taken over by multinational cor- porations, and by the end of the 1990s, more than 90 percent of the coun- try's tobacco industry belonged to multinationals. An almost immediate result of privatization was the unrestrained avail- ability and improved consumer appeal of cigarettes. All international brands could now be found on the domestic market, together with new local brands such as Solidamos6 (Solidarity), Lady Di, Sobieski (named for a famous Polish king), and George Sand. Privatization also led to a rapid shift away from reliance on tobacco grown in Poland, and this, together with the introduction of modern equipment, caused a considerable reduc- tion in the workforce. With the construction of new and technically more advanced factories, the industry's productivity increased substantially. In the rapid privatization, the authorities made considerable con- cessions to the multinational companies, such as agreeing to keep tobacco taxes low for several years. As a result, the real prices of ciga- rettes remained low throughout the first half of the 1990s: a pack of one of the cheapest brands cost less than a loaf of bread. Higher 104 WITOLD ZATONJSKI tobacco taxes that raised cigarette prices were levied only in the sec- ond half of the 1990s. Even so, at the end of the 1990s the tax rate was only 47 percent, while in European Union (EU) countries the minimum rate was 57 percent. The Tobacco LoMby Moves into Action The multinational tobacco companies developed a 'obby to promote their interests. An important part of their efforts involved establishing good relations with the emerging class of polit.cians, parlicularly economic and financial specialists. For example, the tobacco lobby made a donation to Lech Walesa, then leader of the Solidarity trade union, in hopes of gain- ing his support. As soon as they entered the Polish market, transnational tobacco com- panies worked to undermine the traditional ban on tobacco advertising. They were unable to overturn the internal regulations against tobacco advertising on national television (there were no private television chan- nels at the time), but they did manage to overcome restrictions in all other media, including public radio and the press, the first of the media to be privatized. The tobacco companies introduced E,dvertising techniques that Poles had never before experienced. The industry soon became the largest advertiser in the country; toward the end of the 1990s it was spending USSIOO million a year on advertising cigarettes in Poland (National Association of the Tobacco Industrv 1998). The unfamiliar marketing techniques had a powerful effect on a recep- tive public. The decrease in the prevalence of smoking halted, and the number and percentage of occasioaal smokers rose. The most important change was a surge in the number of children experimenting with ciga- rettes, with a particularly dramatic increase in the number of girls who smoked. The percentage of girls between the ages of 11 and 15 who smoked at least once a week increased from 16 percent in 1990 to 28 per- cent in 1998 (Mazur, Woynarowsk,a, and Kowalewska 2000). The opening of the market, the takeover of Polish tobacco companies by the multinationals, and the use of state-of-the-art marketing tech- niques all appeared to have determined the future of the tobacco epi- demic in Poland. The industry set itself a goal of increasing tobacco con- sumption by about 10 percent over 10 years. Predictions concerning health were pessimistic. The evidence of increasing premature mortality among young and middle-aged adults between 1988 and 1991 seemed to confirm such fears (Zatoriski 1995). These growing health threats were challenges for health advocates. But democracy, an emerging civil society, and indea)endent, news-craving mass media also opened up new opportunities for action. DEMOCRACY AND HEALTH: TOBACCO CONTROL IN POLAND 105 The Kazimierz Declaration Even before the political system changed in most Eastern European countries, Poland hosted a conference at Kazimierz in November 1990 with the title "A Tobacco-Free New Europe." The Cancer Centre and Institute organized the conference under the honorary patronage of Lech Walesa, the historic Solidarity leader, and in collaboration with the UICC and the American Cancer Society. It was the first meeting of health advocates from Western and Eastern Europe aimed at taking action to close the health gap between the two parts of the continent. It was also the first opportunity to present comprehensive scientific evi- dence on the magnitude of the health damage caused by smoking in Eastern Europe. The conference targeted public health leaders from Eastern Euro- pean countries. Many of the participants later became national leaders in tobacco-and-health policy in their own countries. Other participants included representatives of leading international health organizations such as the WHO and experts on tobacco and health from Europe and the United States, including Richard Peto of Oxford University; Greg Connolly of the Massachusetts Department of Health, director of one of the biggest tobacco control programs in the world; and Michael Wood from Belfast, then director of the UICC's Program on Tobacco and Cancer. The conference ended with the endorsement of the Kazimierz Declara- tion, which recommended that national governments adopt comprehen- sive tobacco control programs to reduce the health consequences of ciga- rette smoking. The declaration emphasized that in a democratic state, legislation was the key to curbing the damage to health from smoking. It recommended that governments take the following steps: * Introduce and enforce a strict ban on all direct or indirect advertising and promotion of tobacco goods or trademarks * Adopt, as a minimum, EU standards for health warnings on cigarette packs * Adopt, as a minimum, EU standards for maximum tar deliveries but with delays to allow national tobacco manufacturers to comply with maximum levels of 20 milligrams by 1995 and 15 milligrams by 2000 * Ban the introduction of smokeless tobacco and any new forms of tobacco * Impose a substantial health surcharge on all tobacco products to raise the minimum price of cigarettes * Regularly monitor tobacco-related mortality and smoking prevalence * Immediately establish national tobacco control coordinating committees * Recognize the need for smoke-free public environments 106 WITOLD ZATONSKI * Educate the public, especially young people, about the hazards of tobacco use * Support smokers who want to stop srnoking. The Kazimierz conference also provided a framework for cooperation in tobacco control among Central and Eastern European countries. Not long after the conference, the WHO Collaboralting Centre on the Action Plan for a Tobacco-Free Europe was set up at the Department of Epidemiology and Cancer Prevention of the Cancer Centre and Institule. Through it, Poland became a center for educating and training public health leaders in Central and Eastern Europe. The Kazimierz Declaration provided a basis for health-related tobacco control action in Poland in the 1990s. Polish public health advocates saw the Kazimierz conference as a milestone in formulating objectives and as a catalyst for work on a parliamentary bill to reduce cigarette smoking with the goal of improving the health of the PoLish peopIc. Not surprisingly, the international tobacco industry viewed the conference with anxiety. Establishment of the Health Promotion Foundation In the new political milieu, nongovernmental instititions could be set up to achieve public goals. The Health Proimotion Foundation was estab- lished to organize and support health promotion activities aimed at pre- venting smoking-related diseases and increasing consumption of fruits and vegetables.' Its continuing activities include: * Developing and offering education programs * Supporting scientific research * Cooperating with local and international organizations such as the UICC and the WHO * Organizing and making presentations at conferences and workshops. The foundation's tour de force has been a mass campaign to help smokers quit. This drive takes place every autumn, climaxing on the third Thursday in November. Its Polish name can be translated as the Great Pol- ish Smoke-Out, and it is based on the Great American Smoke-Out cam- paign. Within a few years, it became the largest regular public health cam- paign in Poland. Originally central]y organized, the campaign now relies on the active involvement of local communities and local media. 1. The foundation was set up by the author Its ILmited 'iudget comes from private donors, and its project funding, from international and other organizatiDns. Its work is greatly facil- itated by a strong partnership with Polish media. DEMOCRACY AND HEALTH: TOBACCO CONTROL IN POLAND 107 Studies tracing the campaign's impact year by year have shown that 80 to 90 percent of Poles have heard of it. Many smokers credit the campaign with inspiring them to smoke less or stop smoking (Jaworski, Przewozniak, and Zatonski 2000): * Every year, 20 to 30 percent of smokers have tried to smoke less. * Every year, about 1 million smokers (out of about 9 million daily smok- ers) have attempted to quit smoking. * Every year, 200,000 to 400,000 people claim to have quit smoking thanks to the campaign. Over more than a decade of campaigns, more than 2 million people have successfully quit smoking for good. These impressive results testify to the campaign's importance in improving the health of Poles. Part of the campaign's success comes from a popular annual competi- tion. All Poles who have quit smoking since the beginning of the year can take part simply by sending in postcards to the Health Promotion Foun- dation. The competition has become more popular each year, and in 2000, the 10th year, more than 40,000 postcards were submitted. The prize, awarded to a number of randomly chosen participants, is a one-week stay in Rome, including a private audience with Polish-born Pope John Paul II. Both public and commercial media support the program, with public radio and television being tbe main media sponsors. Every year, thou- sands of news items describe l-he campaign. Special advertisements, infor- mation on how to quit, di,cussions, and reports are broadcast and printed. The competition and the trip to Rome traditionally receive wide television coverage. New Legislalion for Tobacco Control In 1989 the upper chamber of Parliament, the Senate, became the first democratically elected politic il institution in postwar Poland. Because of their high social status, medic al professionals formed an unusually high proportion of senators. Cons equently, health advocates chose to begin legislative action in the Senatr. Soon after the Kazimierz conference, a working group at the Cancer Centre and Institute developed a preliminary draft of a tobacco control bill, together with a statemen Lt of reasons for approving it. The health- related arguments presented were backed up with scientific evidence, which included the dramatic level of premature mortality in Poland caused by inhaling cigarette smoke. The bill was based on WHO stan- dards for good tobacco contro I legislation and included a comprehensive set of provisions for reducing 2igarette consumption. 108 WITOLD ZATONSKI Politicians, and especially the medical professionals holding senatorial posts, welcomed the draft bill. A working group lheaded by Dr. Maciej Krzakowski of Cieszyn was formed in '991 to prepare the motion. Soon afterward, the bill was introduced in the Senate. Controversy C'ver the Proposed Bill To the surprise of politicians and health advocates, the bill encoun- tered strong opposition from the tobacc3 lobby. For the first time in the new democratic era, politicians were faced wvith the activities of a well- organized interest group determ-ined tc achieve its goals. The controversy over the bill soon became public. The health of Poles and the harm done by cigarette smoke became the subject of a stormy public debate lasting many years. The media, now independent, but not always free of external influences, played a key role in the debate. The health evidence was irrefutable-whic& is not to say that the tobacco industry has never questioned it. The cliscussion therefore centered on whether legislation (which is, after all, a piece of paper) could improve the health of a nation. Cigarette companies tried to make parliamentarians (and the entire nation) believe that the legislaticon would be ineffective. They questioned the efficacy of an advertising barL, health warnings, economic regulations, and education, and they referred to freedorn of advertising. Above all, they warned that a ban would have a negative imFact on Poland's future economic development. Initially, the media and public opinion were skeptical about the need for the legislation. \AThat seemed to turn public opinion was the consis- tent argument by health advocates tha: smoking was largely responsi- ble for the catastrophic state of the health of adiult Poles. In the last stage of the debate, opponents of the bill, now losing ground, concen- trated their attack on the proposed advertisi-ng ban. The maintenance of the right to advertise cigarette products became a key area of possible compromise. On the government side, financial decisicrnmakers disagreed with the proposal to allocate some tobacco tax revenue for financing actions to improve health by reducing smoking. .[n general, however, support for the legislation was rising among politicians a nd the public, irrespective of political affiliation. Public attitudes toward smoki-ig were changing. The ongoing public debaLe had drawn the att:ention of Ploles to the health costs of smoking, and they were alsc, becoming more aware of reduced toler- ance for smoking in other countries. As public awareness increased, polit- ical parties took notice. DEMOCRACY AND HEALTH: TOBACCO CONTROL IN POLAND 109 The Bill Passes In a country where democracy was only beginning to take root, a succes- sion of short-lived governments might have been vulnerable to the efforts of the tobacco lobby to derail the bill. The industry encouraged the use of a presidential veto and, failing at that, sought at least to delay the passage of the bill as long as possible. But no matter which political party domi- nated Parliament, the work and the debate on tobacco control legislation continued. On November 9, 1995, the Law for the Protection of Public Health against the Effects of Tobacco Use passed with an overwhelming majority (90 percent) of votes from all political parties. Some of the key areas covered by the new act were * Smoking bans in health care establishments, in schools and other edu- cational facilities, and in closed spaces in workplaces. * A ban on selling tobacco products to minors under 18. * A ban on selling tobacco products in health care establishments, schools and other educational facilities, and sports facilities. * A ban on selling tobacco products in vending machines. * A ban on producing or marketing smokeless tobacco products. * A total ban on advertising tobacco products in electronic media (radio and television). * Restrictions on advertising in other media. (Advertisements in print media and on billboards had to carry health warnings in the upper part of each advertisement, occupying 20 percent of the area.) * Publication of health warnings on all cigarette packs. (The warnings were to occupy 30 percent of two of the largest sides of each pack.) * Free provision of treatment for smoking dependence. With the exception of two areas-lack of a total advertising ban and of a fund dedicated to improving smokers' health-the new law included all the actions outlined in the WHO's gold standard for tobacco control. The Polish legislation effectively provided for the protection of non- smokers and introduced the world's largest health warnings on cigarette packs. It also obligated the government to prepare annual action pro- grams for controlling the health consequences of cigarette smoking. Implementation reports have been presented to Parliament every year since then. The new regulations were enforced without much trouble, although there were some technical problems. For example, no company or indus- trial enterprise had a separate ventilated room to allocate for smokers' use. As a result, the regulation on implementing this measure only 110 WITOLD ZATOKSKI became effective after five years; the provision of special rooms finally became a requirement on January 1, 2001. WVithin a short time, many workplaces, particularly in the private sector, became truly smoke-free, allowing smoking only in specially designated places. Tihe Indutstry Strikes Back Having succeeded in preventing a total ban on tooacco advertising, the tobacco lobby immediately launched an aggressive campaign against the placement of large hea]th warnings on cigarette packs. The lobby main- tained that the new legislation was inconsistent with current EU regula- tions and would hinder Poland's admission to the EU. Industry officials feared that these health warnings, the first to be introduced in a European country, would create a precedent. They were right. A few years later, the European Parliament referred to the Polish example as it began action to implement even larger health warnings on cigarette packs sold in EU counrtries. Warnings that occupy 30 to 40 percent of the two larger sides of a cigarette pack are being intro- duced in the EU in 2003. A pro-tobacco parliamentary lobby was mobilized on an unprece- dented scale to try and thwart the plans lo introduce the health warnings. Many Polish politicians regard the scope and intensity of that lobby as the most powerful in the entire first decade of parliamentary democracy in the country. For health advocates, the of Fensive against the existing legis- lation provided another opportunity to call the public's attention to the health catastrophe resulting frorn cigareltte smoke. The fight of the tobacco industry's Goliath against the health advo- cates' David came under intense scrutiny in the media and even received international coverage. Undaunted by successive defeats, the tobacco lobby made three attempts to change the 1995 legislation during the vaca- tio legis (the period between the promulgation and the implementation of a law). The last attempt, a few months before the 1997 elections, was marked by a vigorous debate that alrmost resultecl in a physical fight in Parliament. In spite of the enormous political and f nancial effort, on April 11, 1997, the tobacco lobby lost the battle to change the size of health warnings on cigarette packs. TIhis time, however, the majority was small: 148 in favor, 122 against, and 100 abstentions. In mid-1998, after two and a hlalf years of negotiations, Parliament finally confirmed that health warnings on cig,arette packs sold in Poland were to occupy 30 percent of the two larger sides of the pack. These were the largest warnings in the world until Canada in:roduced larger, pictor- ial warnings in 2001. DEMOCRACY AND HEALTH: TOBACCO CONTROL IN POLAND 111 Figure 5.4. Nominal and Real Trends in Tobacco Excise Taxes and Average Monthly Salaries, Poland, 1993-2002 Nominal average tax per pack 2500 2.50 - _ Real average tax per pack a Nominal average salary g 2.00 2,000 o r150 1,500 a. CL~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~C 1.00 1,000 = m ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~CD CD ) 0.50- 500 June March April Dec. Feb. Jan. April Jan. Oct. Jan. 1993 1994 1995 1995 1997 1999 1999 2000 2000 2002 Source: Cancer Centre and Institute, Warsaw. The Role of Cigarette Pricing In privatization agreements concluded in the early 1990s, the government had agreed to freeze tobacco taxes. As a result, in the first half of the 1990s increases in cigarette prices remained below the inflation rate (which was high at the time), and taxes on cigarettes never exceeded 30 percent of the retail price, compared with the EU minimum of 57 percent and an EU average of about 75 percent. Increases in nominal cigarette prices matched income growth, and so cigarettes become increasingly affordable throughout the decade (figure 5.4). The 1995 act stipulated that the government must take effective eco- nomic action through a pricing policy designed to limit tobacco use. In 1997 health advocates began collaborating with the World Bank and the Univer- sity of Chicago to investigate the economics of smoking in Poland. The work included analyzing the effect of cigarette taxes and price increases on smoking behavior (see, for example, Zatoriski, Matusiak, and Przewozniak 1998). The preliminary results of this analysis showed that higher taxes and higher cigarette prices would result in a decrease in the number of ciga- rettes smoked and an increase in total tax revenues. Only when these results 112 WITOLD ZATONSKI were presented did the rate of tobacco tax increases accelerate. In 1999 and 2000 the tax on tobacco products increased by approximately 30 percent each year. It must be stressed that t:his economic tool-higher taxes that raise prices-has a particularly strong impact on less well-educated and poorer people. This is often the group with the highest smoking prevalence and the least likelihood of quitting in response to information about the harmful health effects of smoking (Abrld Bank 1999). Unfortunately, not all politicians and economists are convinced of the effectiveness or advisabil- ity of using prices as a tool for limiting tobaccc use. Advertising Back on the Agenda In 1998 a newly elected Parliament moved tobacco advertising onto the agenda once again. Parliamentarians vwere alarmed by new evidence showing a decrease in the age at which children (especially girls) begin smoking (Mazur, Woynarowska, and Kowalewska 2000). They were also responding to growing public concern about aggressive advertising by tobacco companies, which Poles regarded as being targeted mostly at chil- dren. There was a general consensuis that these two factors-the growing popularity of smoking among children and aggressive cigarette advertis- ing-were directly related and could be changed by a total ban on ciga- rette advertising. A new bill was introduced and this time moved rapidly through Parliament. A total ban on tobacco advertising was passed on September 10, 1999, by a large majority: 374 in favor, 11 against, and 12 abstentions. All political parties endorsed the bill. The new law included a provision for allocating 0.5 pe-cernt of tobacco excise tax revenue to the National Tobacco Program with the aim of redu,-ing the health conse- quences of smoking. By December 2000, tobacco advertisements had been removed from billboards all over the country. Since 2001, tobacco adver- tising has been banned in all print medLia. The progress of this bill, the parliamentary cLebate, and the media commentaries reflected the change in Polish society's attitude toward smoking. The decrease in smoking prevalence a -d the interest among smokers in trying to quit are striking. International studies indicate that the climate in Poland for health improvement through reducing tobacco consumption is one of the most favorable in Europe (Fagerstr6m and others 2001). Democracy Is Healthier Democracy and a free-market economy have turned health into an impor- tant value in personal and family welfare in Poland. Pro-health behavior, the growing share in the Polish diet of vegetable<, and fruits (now avail- DEMOCRACY AND HEALTH: TOBACCO CONTROL IN POLAND 113 able in great variety all year round), the popularity of a Mediterranean diet, and sports-all are at odds with inhaling tobacco smoke. The change in attitude toward smoking is most noticeable among educated Poles who have more experience of life in other countries, especially in the United States, and are aware of a lack of tolerance there toward smoking. In cer- tain communities, being a nonsmoker has become fashionable, and smok- ing no longer receives social approval. Quitting smoking is a popular New Year's resolution. Local and religious communities have become an important setting for discussions about the health effects of smoking. The Catholic Church is the main sponsor of the annual November antismoking campaign, and it also encourages nonsmoking at the local level-for example, when priests meet with engaged couples. Schools are also active in health promotion, helping to increase awareness of the dangers of tobacco use. The activities are aimed at parents, as well as at students and teachers. Consumption Drops Dramatically In the 1990s sales figures for cigarettes in Poland decreased for the first time since World War II. Tobacco industry data show that cigarette con- sumption fell by 10 percent between 1990 and 1998 (Michaels 1999). This reduction was achieved when the market was functioning normally and despite the enormously aggressive advertising policies of the tobacco companies. (As noted above, in the late 1990s the tobacco industry was spending US$100 million annually on advertising.) The drop in cigarette consumption was the result of reduced smoking prevalence in many different groups in society (Zatoiiski and others 2000). As figure 5.5 shows, smoking prevalence among men decreased in all age groups between 1975 and 1999. For women, a reduction in the popularity of cigarette smoking has been observed mainly in the younger age groups. The least significant reductions and the highest smoking prevalence are among middle-aged Poles of both genders, with no decline in prevalence evident (yet?) among middle-aged women. The overall decrease in smoking is most marked among better educated groups; among less well-educated Poles, the decrease in smoking is much less. To sum up, smoking in Poland peaked at the end of the 1970s, with approximately 14 million smokers. At that time, 62 percent of all adult men and 30 percent of adult women smoked, and percentages for many age groups were higher. Prevalence levels remained at these levels in the 1980s but decreased substantially in the 1990s. At present, slightly fewer than 10 million Poles smoke-about 40 percent of adult Polish men and a little more than 20 percent of adult Polish women. 114 WITOLD ZATONKSKI Figure 5.5. Smoking Prevalence by Age Group, Men and Women, Poland, 1975,1985, and 1999 Men 70 ------ * 1975 *1985 60 ---------- 1 999 50 ---- ---- -- -- -- -- 2 4 0 -- ---- - - 30 20 - -- -- 10 ---- - -- 0 1 20-29 30-39 40-49 50-59 60+ Age group Women 4 0 -- - - - - - - ---- - - - - - - - - - 35 ----- ------------- - 30 - - - -- - ---- - - - - - - - - - - 25 - _-------- ---- o 20 --- -- . -X 15 -- - - - - - - - - - 10 -- l- - - -- 5 - 20-29 30-39 40-49 .50-59 60+ Age group Source: Cancer Centre and Institute, 'Narsaw, using data from the Central Statistical Office of Poland (various years). Health Indicators Improve? The drop in smoking across much of the Polish population has improved the country's health indicators. As noted at the beginning of this chapter, the incidence of ling cancer is the best and most specific DEMOCRACY AND HEALTH: TOBACCO CONTROL IN POLAND 115 measure of changes in exposure to tobacco smoke. In Poland shifts in this epidemiological indicator clearly reflect the history of exposure of the Polish population to cigarette smoke. The upward trend in lung cancer mortality in the youngest age group of adult men (age 20-44) was reversed in the 1980s, and by the end of the 1990s mortality had decreased by about 30 percent from the peak level. A 19 percent decline in lung cancer mortality in middle-aged men (age 45-64) followed in the early 1990s. In the over-65 population, the effects of the changes in exposure to cigarette smoke are still not evident. In Hungary trends in lung cancer incidence before 1980 were similar to those in Poland. Hungary has not implemented effective tobacco control measures, and unlike the trend in Poland, the incidence of lung cancer is still increasing. The current incidence figures in Hungary are the highest ever for young and middle-aged adult men and women. In the United States and the United Kingdom, by contrast, trends in the epidemiology of lung cancer resemble those observed in Poland, although over a differ- ent time period (see figure 5.2, above). Paralleling the changes in lung cancer mortality in Poland are decreas- ing mortality trends for other tobacco-related cancers, such as those of the oral cavity, larynx, and pancreas (Zatoiiski and Tyczyniski 1997). Another positive change since 1991 has been a significant 20 percent reduction in cardiovascular disease (Zatoriski, McMichael, and Powles 1998). About 10 to 40 percent of all cardiovascular disease in Poland is estimated to be tobacco-related. (The range reflects age-group and gender differences.) Exposure to cigarette smoke plays a less important role in cardiovascular disease than in lung cancer, but some of the decrease in cardiovascular disease is probably due to reduced exposure to cigarette smoke. The reduction in smoking in Poland in the 1990s was also a factor in the drop in infant death risk during that decade. The lower risk is related to a decrease in the percentage of infants with low birth weight (<2,500 g)-from 8.4 percent in 1989 to 5.9 percent in 1999 (Szamotulska and others 2000). An estimated 20 to 30 percent of the reduction in risk can be attributed to lower exposure to cigarette smoke among pregnant women and their unborn and newborn babies. Between 1985 and 1999, the prevalence of smoking among women age 20-29 dropped signifi- cantly, by about 23 percent. Overall, the total mortality rate in the Polish population from all causes fell by about 10 percent between 1991 and 2000, corresponding to a decrease of nearly 36,000 deaths annually. The reduction in cigarette consumption is estimated to be responsible for about one-third of the reduction in mortal- ity across all age groups, or about 10,000 deaths a year (Zatoiiski 2000). Life expectancy-the best overall health indicator-increased in the 1990s by almost four years for men and almost three years for women. 116 WITOLD ZATONSKI Lesscns Learned Despite the significant progress in the past decE de, Poland's journey toward health improvement through tobacco control is just beginning. The experience gained in these earLy stages will provide the foundation for future strategies. Strong Warnings Hcave an Impact One focus of early efforts has been on increasing public awareness of the health hazards of smoking. A vaLuable tool in raising awareness has been the large, clear warnings on cigarette packs. As a result of the introduction of the warnings, 3 percent of smokers stopped smoking, 16 percent attempted to quit, and another 16 percent are ncw more aware of the harm done by smoking (Zatoniski, Przewozniak, arLd Porebski 2000). Pricing Policy Is Kely, Especially for the Health of People with Low Incomes The message about the harmful effects of cigarette smoke has mainly influenced better-educated Poles. Among people with basic education, including pregnant women, smoking prevalence his decreased very little (Zatoriski and Przewozniak 1999). Cigarette prices have been rising at a slower pace than incomes, which makes cigarettes more affordable and tends to increase consumption, especially among lower-income groups. Pricing policy is an area of strategic importance for further limiting the health consequences of cigarette smoking. The World Bank's review of evidence shows clearly that it is the strongest and most effective single measure (World Bank 1999), and recent observations in Poland have con- firmed this (Czart and others 2000). But the reduction in tobacco con- sumption that Poland has achieved so far is not a ttributable to the intro- duction of a pricing policy, since significant price increases occurred only after 1997. Taxation policy has only just begun to be used to reduce tobacco use in Poland, and more could be done. Doctors and Other Medical Professionals Need to Do More Medical advice is another effective method o F mot-vating smokers to quit. Even though the antismoking climate in Poland is one of the most favorable in Europe, the contribution of physicians and other medical professionals to treating tobacco-dependence syndrome rernains insignificant. Only 2 to 3 percent of ex-smokers report rmedical assistance in quitting. Polish ex-smokers are mostly those who were the least addicted. Nearly one-half of daily smokers (about 4 rmillion) smoke their first ciga- DEMOCRACY AND HEALTH: TOBACCO CONTROL IN POLAND 117 rette within the first half-hour after waking up. In the most addicted cases, 8 percent of adult male smokers and 4 percent of adult female smokers (a total of 0.5 million people) wake up during the night to smoke a cigarette (Zatoriski and Przewozniak 1999). The smokers with the strongest addiction and the greatest exposure to cigarette smoke are those born between 1940 and 1960. They reached ado- lescence (and started smoking) between 1955 and 1975, a period of wide- spread social acceptance of smoking. Smokers in this group either already suffer from severe smoking-related health problems or will before long see symptoms of the health damage caused by their smoking. This group should receive special medical attention and should be the target of care- fully designed immediate interventions. Stopping exposure to cigarette smoke always brings substantial health benefits, even after many years of smoking (Peto 2002). Nicotine addiction is a medical problem, so supporting those who want to quit or have quit is a special task for physicians. Both general practitioners and specialists (cardiologists, pulmonologists, obstetricians, pediatricians, and oncologists) should be made aware that helping people cure their tobacco addiction is part of a doctor's responsibility to his or her patients. It is impossible to cure patients of major diseases, such as chronic bronchitis and cardiovascular diseases, including coronary heart disease, without first getting them to quit smoking. Health providers in Poland are becoming more involved in helping patients stop. Some health insurance policies cover treatment to help people stop smoking, which makes economic sense, since smokers have much higher annual health care costs than nonsmokers. Another great challenge in Poland that demands immediate action and a long-term campaign is reduction of pre- and postnatal exposure to tobacco smoke. Smoking during pregnancy and exposure of young chil- dren to cigarette smoke remain problems. In fetal and infant life, second- hand smoke is an important contributing factor to poor health. Interven- tion programs supported by local communities should be undertaken to protect children from this risk. Science-Based Evidence Is Important to Justify Action In all of Poland's tobacco control efforts, solid scientific evidence has played a key role. It has helped convince the general public of the dangers of tobacco consumption and has provided the justification for programs and legislation. The Polish experience in changing people's attitudes toward smoking shows the dominant role of medical evidence. This evidence, based chiefly on domestic data compiled in collaboration with leading research centers abroad under the auspices of the WHO, demonstrated the extent 118 WITOLD ZATONSKI of the epidemic of diseases caused by inhaling cigarette smoke. In partic- ular, highlighting the causal relationship between cigarette smoke and cancers, especially lung cancer, proved to he a good tactic. People viewed news on this link as reliable because the informalion came from the national Cancer Centre and Institu te and was endorsed by prominent sci- entists. The ready acceptance of this information in the late 1980s may have been the result of increased awareness oF the problem as the epi- demic of tobacco-related diseases reached its peak. Poles were able to compare the health messages and scientific evidence with news about the health of their relatives and friends who were smokers. Legislation Is Essentialfor Progr?ss in Tobacco Control Another important contribution to Poland's progress in tobacco control has been the legislation enacted in 1995 and 1999. The years 1990 to 1995, in particular, when the tobacco control law was drafted, were crucial to the later success of tobacco control efforts. Especia]ly effective was the debate surrounding the bill, when the public heard thne strong health evi- dence against smoking and observed the tobacco industry's actions to prevent the bill from being passed. The process of introducing and defending the legislation provided a forurn for changing public attitudes toward tobacco, especially among the best-educated groups of society. One important lesson from the Polish experience in preparing the bill is that legislative tactics must correspond to the level of public awareness of the issue. In the early 1990s Poles did not understand the importance of a total ban on tobacco advertising f-or reducing the health consequences of tobacco smoking. Only after years of watching the practices of the tobacco industry and following the national debate dicL people change their atti- tudes. This is reflected in the initial rejection oF the i:otal advertising ban in 1995 and its adoption in 1999 'by an overwhelming majority of votes and with support from all political parties. Both the 1995 legislation and its 1999 amnendment have proved instru- mental in changing the attitude of P'oles toward tobacco use. Still, this transformation should be viewed as a phased process rather than a revo- lutionary change. Large, clear health warnings on cigarette packs that stig- matize the product, a ban on smoking in public places, and a total ban on tobacco advertising help reinforce this attituhdinal change day after day. Local Involvement in Tobacco Control Effcrts Is Crucial Rapid further progress in tobacco control is not possible without the involvement of local communities. 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Tyczyriski, P. Boyle, in collaboration with N. Becker, J. Didkowska, H. P. Friedl, J. Holub, Z. Feter, 1. Plesko, V. Roman, R. Stabenow, and C. Tzvetanskv. 1996. Atlas of Connfer Mortality in Central Europe. IARC Scientific P'ublications 134. Lyon, France: International Agency for Research on Cancer. Zatoriski, W., K. Przewozniak, M. Porebski, U. Wojciechowska, W. Tarkowski, and E. Harville. 2000. "The Smoking, Decline in Poland: Does It Apply to All Socioeconomic Classes?" In "Worksl op and Poster Session on Challenges to Tobacco Control for Eastern Europe in the 21st Century, August 8, 2000. Eleventh World Conference on Tobacco or Health--Promoting a Future Without Tobacco, August 6-11, 2000, Chicago, [11." Abstracts: 50. 6 Political Change in South Africa: New Tobacco Control and Public Health Policies Mia Malan and Rosemary Leaver Over the past decade, there has been a dramatic turnaround in the South African government's attitude toward tobacco control. Before 1993, tobacco control policy was virtually nonexistent, but the 1999 Tobacco Control Amendment Act gave the country some of the most progressive tobacco control policies in the world. Today, all tobacco advertisements and sponsorships have been banned; smoking at work and in restaurants is illegal, except in clearly demarcated areas; and explicit health warnings are required on all cigarette packs. Although cigarettes are still relatively cheap in South Africa, excise taxes represent almost 50 percent of their total retail price, after significant increases in 1994 and again after 1997 (van Walbeek 2002b). As a result of these policies, cigarette consumption is on a downward spiral. According to Corne van Walbeek of the School of Economics, Uni- versity of Cape Town, it decreased from 1.9 billion packs in 1991 to about 1.3 billion packs in 2002. The rate of decline has accelerated especially since 1997, when large tax increases sharply increased the price of ciga- rettes. In light of these accomplishments, many today regard South Africa as a model for other countries. But these gains have not come easily. They are the result of decades of steadfast lobbying by the health community and antismoking groups and of the new South African government's commitment to public health. And they have come in the face of vehement opposition from the tobacco indus- try, advertising agencies, hospitality associations, and, until the early 1990s, an apartheid government with extraordinarily close links to the trade itself. The History: Early Days, Early Struggles As long ago as September 1963, the South African Medical Journal, in a far- sighted editorial, offered advice to the health minister of the time: 121 122 TMIA MALAN AND ROSEMARY LEAVER There should be no hesitation about banring smoking in public places and on public transport.... Cigarette advertising should at first be restricted as to quantit) and content with a view to its eventual limita- tion. It might also be advisable to insist that each cigarette packet should carry a notice to the effect that the conterts are potentially dangerous to health. The minister of health rnay also attenmipt further restrictions of smoking by increasing the taxation on cigarettes.... The matter is impor- tant and urgent. Dr. Yussuf Saloojee, executive director of the National Council Against Smoking (NCAS), has ironically remarked that these suggestions were considered so "important and urgent" that 12 years passed before a sin- gle one of them was acted on (Saloojee 1993a). In 1975 the tobacco indus- try volunteered not to advertise cigarel-tes on television, but it took another 12 years for it to agree to print on cigar2tte packs a warning ("Smoking is a health risk.") that was "vaguely worided, badly placed and in very small print" (Hansard 1993). "A Crime of Apa2rtheid" Some have maintained that the government's historical lack of interest in tobacco control was "a crime of apartheid," arguing that the tobacco indus- try was dominated by white, Afrikaans-speaking So oth Africans with very close ties to the government (WilkWns 2000). The h istory of the tobacco industry in the country, particularly prior to 1993, bears out this view. The tobacco manufacturing industry in Sou th Africa is very highly con- centrated. The Rembrandt group used to control 87 percent of the market, with British American Tobacco South A,rica (BAT'i being the only other company with any significant market share. Under the able leadership of the Afrikaner businessman Anton Rupert, Rembrandt developed into a very successful corporation, and it is often perceived as a symbol of the Afrikaans-speaking community's rise to economic power. After its merger with Rothmans International, it gained control of 95 percent of the mar- ket. Rupert retained a strong hand through his control of two companies, Remgro and Richemont, that owned 30 percen-t of 13AT. Rupert became one of the most powerful businessmen in South Africa: he built up strong links with virtually every major decisionmaker, includ- ing legal firms and media institutions, and was on the board of most major trusts. Yach (2002) recalls that "anywhere you turned in the media and tried to get a story published that advccated tobacco control, you were blocked by their absolute fear and tre]pidation of Rupert's long reach through his tobacco companies." Ironically, Rupert's wife was involved with South Africa's Cancer Association, while her husband's products were killing many of the people she was aightng to keep alive (Yach 2002). POLITICAL CHANGE IN SOUTH AFRICA 123 Rembrandt had a long history of backing the National Party, which was dominated by Afrikaans-speaking South Africans. The two were, in fact, founded in the same year, 1948, and "grew up together" (Yach 2002). The National Party represented Afrikaner political power, and an unhealthily close relationship between the tobacco industry and the gov- ernment had far-reaching implications for policymaking. In the early 1990s Rembrandt rebuilt one of then-president F. W. de Klerk's homes, and there were annual Rembrandt-funded outings for cab- inet ministers. For its part, the National Party government demonstrated a favorable attitude toward the industry through low excise taxes, virtu- ally unrestrained advertising, and an absence of restrictions on smoking in public places. For instance, within party circles, it was well-known that F. W. de Klerk's predecessor, P. W. Botha, strongly disliked smoking-so much so that he forbade it at cabinet meetings. Yet Botha never expressed his attitude in antitobacco measures (Perlman 1991a). During this time, the tobacco industry (in effect, Rembrandt) was the Ministry of Finance's prime adviser on cigarette excise matters, with no indication of any Ministry of Health influence. This was clearly reflected in Finance Minister Barend du Plessis' 1983 budget speech, when he warned, "The Tobacco Board has presented justified arguments for the maintenance of the status quo regarding the excise taxes on tobacco and I do not intend to wake sleeping dogs." Three years later, in 1986, du Plessis again refused to increase excise taxes on cigarettes, arguing that any tax increase could adversely affect consumption and lead to a reduction of revenue (van Walbeek 2002a). At the time, excise taxes accounted for less than 30 percent of the retail price, and the real excise rate on tobacco had been decreasing steadily for the previous 15 years, eroded by inflation. It is hard to imagine that the minister's grasp of basic economics was so flawed that he believed his own statement. He, like his peers in many countries around the world, would have known very well that a tax rate increase would in fact lead to an increase in revenues. The decrease in consumption in response to a price increase would be smaller in percentage terms than the tax rise. The higher tax revenues per pack would generate higher total revenues, despite a somewhat lower sales volume. The Cape Town Debate The effect on policy of the relationship between the government and the tobacco industry became evident in 1989, when the Cape Town City Council announced plans to restrict cigarette advertising and smoking in public places. In protest, Rembrandt threatened to withdraw its sponsor- ship of the Cape Town Symphony Orchestra. The company's influence 124 MIA MALAN AND ROSEMARY LEAVER went well beyond its sponsorship: it comrnanded a-i enormous network of power and influence, and there was a si gnifi cant threat of retribution if its wishes were thwarted. Rembrandt's tactic worked: Kobus Meiring, the administrator of the Cape Province, refused to pass the legislation needed to enforce the council's plans (Dertnehy 1989a'. The restrictions, which had been proposecd by Dr. Michael Popkiss, Cape Town's chief medical officer, would have required restaurants to set aside at least half their tables for nonsmokers (Doman 1989a). Existing by- laws outlawed smoking only on the lower decks of buses, in cinemas, and in public elevators. New restrictions on tobacco advE rtising were also pro- posed: in addition to the ban on cigarette commercials on television, cig- arette advertising would be prohibited in all council-owned buildings and properties (Dennehy 1989a). Four days before the council debate on the proposal, Popkiss wrote to Anton Rupert appealing for funds for an AIDS awareness campaign. An outraged Rupert turned down the request, saying that his refusal came "from an industry you have decided to destroy" (BatE man 1989b) in pursuit of "not only dictatorial, but clearly impracticab]e" objectives (Morris 1989). The exchange prompted Cape Town mayor Peter Mlller to rebuke Popkiss for his insernsitivity and bad timing, declaring that he found it "incongruous that the [medical officer] can write a finanicial appeal only four days before a major smoking debate-he must either tiink that Dr. Rupert is foolish, or alternatively, he's totally devoica of any sensitivily" (Bateman 1989b). Muller's chastisement was immensely embarrassing to the medical officer, as it was highly irregular for a mayor to publicly rebuke a city official. At the council debate, strong support vwas shown for the proposal, with 25 councillors voting in favor and, only 5, including Lhe Cape Town mayor himself, against. A palpable discomfort existed, however, between Pop- kiss and the administrator and mayor. This tension was exacerbated by the leak of internal correspondence between Rupert and Popkiss in which the Rembrandt chair accused Popkiss of being "hell-bent to create new regulations against the freedom of the individual to decide for himself" (Bateman 1989b). To worsen the situation, there waE a further leak of a let- ter from the mayor to the council's executive committee in which he was highly critical of Popkiss and his suggested regulations. The publicity surrounding this feud sparked a heated debate in the let- ters pages of Cape Town newspapers. The National Council Against Smoking, the Heart Foundation, the Cancer ASssociation, and the Medical Association of South Africa sprang to Popkiss's defense, praising him for creating awareness about the health hazards of smoking and pledging their full support for the bylaw. The restaurant industry, which had remained silent until then, began actively voicing its concerns. A local organization, thie Cape Restaurateurs POLITICAL CHANGE IN SOUTH AFRICA 125 Association, gave the council 12 days to withdraw the bylaw or face the threat of court action. When the Cape Town council refused to oblige, the association issued a summons, stating that the ban was "irregular, ultra vires, invalid and unreasonable" (Doman 1989a). The Federation of Hotel, Liquor and Catering Associations of South Africa (FEDHASA) organized a petition signed by 307 Cape Town restaurants to protest the new bylaw. The restaurateurs' primary objections were that the bylaw infringed on their right to decide how best to run their businesses (Doman 1989a) and that some restaurants were too small to be reasonably expected to divide their eating areas (Leaver 2002). The Cape Town Chamber of Commerce did not remain silent either: it argued that business in South Africa was already overregulated and that "efforts should be directed toward doing away with regulations rather than devising more ways to inhibit business activity" (Cape Town Chamber of Commerce 1990). Against the fierce opposition to the bill, the health lobby made a com- pelling case based on the health hazards posed by smoking and inhaling secondhand smoke. And a large majority of the Cape Town public sup- ported restrictions on smoking in enclosed public spaces. The bylaw was only one step away from becoming effective when it was vetoed by Cape Province administrator Meiring. In response, Popkiss commented that he "had never been in favor of the 50-50 rule anyway, because [it] had not been shown to protect non-smokers" (Leaver 2002). The Evidence against Tobacco Mounts Meanwhile, a small success was achieved in a different arena. Key play- ers in the public health community, including Prof. Harry Seftel, then at the Medical School of the University of Witwatersrand, and Drs. Derek Yach and Krisela Steyn of the Medical Research Council, were compiling evidence on the harm caused by tobacco in South Africa and on the high costs that tobacco use imposed on both the state and patients in the form of treatment costs for tobacco-related illnesses, forgone earnings, and pre- mature deaths. As early as 1982, Yach published one of the first tobacco control arti- cles in the South African Medical Journal. His study was considered so controversial that the Medical Research Council refused to publish it under its own name but instead listed it as a personal contribution. The study focused on the economic aspects of smoking in South Africa, claiming that "while it is true that a reduction in tobacco and cigarette production would cause some losses to the national economy and indi- viduals, it is also true that the reduction in total costs accompanying such a decrease would more than compensate these losses" (Yach 1982). Encouraging authors to publish studies under their own names was "a 126 MVIA MALAN AND ROSEMARY LEAVER highly exceptional stance to take," indicative of even the medical estab- lishment's fear of "the impact o] negative reactiorLs of tobacco compa- nies" (Yach 2002). But the persistent efforts of Yach and his coleagues eventually paid off. In 1988 they succeeded in arranging a special "tobacco focus" issue of the South African Medical journal, to coincide wAith the first World No Tobacco Day. It was the first time ever that an entire issue of the Journal had been devoted to one preventive aspect of public health, and it was considered a major breakthrough in tobacco control. Yach described it as a critical turning point because "we were not just saying the cleaths were rising, we started getting a projection of what was going to happen in the future and introduced the fact that there were practical )egislative options that had been taken around the world." IThe lournal had a huge impact in South Africa, receiving extensive coverage and discussion and helping set a basis for future action. So, the publication of the special issue was a first step toward "bridging the gap between epidemio ogical data sitting in scientific journals and popularizing the data in the mass media and among political groups" (Yach 2002). The high medical costs of treating smoking-related illnesses at hospi- tals were drawn to the public's attention. In an editorial in the South African Medical Journal, Anton Rupert was accused of using "emotive lan- guage" to obscure facts, including the fact that "smoking caused almost half of the cases at Groote Schuur, Cape Town's premier hospital" (Bate- man 1989b). These realities did rot elude authorities at the University of Cape Town, who used the hospital as a training facility. In March 1989 smoking and the sale of cigarettes were banned in all public areas of the medical school campus, including cafeterias and bars (Cape Argus 1989b). As political opportunities emerged in Lateir years, the strong evidence base helped support and justify actions. Yach (200X') saw the first indica- tion of success in 1991, when initial documents of the new African National Congress (ANC) government's Reconstruction and Develop- ment Plan strongly featured tobacco contirol as an intended policy. It was helpful that a number of people who eventually assumed senior posi- tions in the government had becorne colleagues of Yach and Steyn in the Medical Research Council in the years just prior to :he turnover of power. The most prominent of these were Dr. Nkosazana Zuma, who was health minister from 1994 to 1999, and Dr. Olive Shisana, who became director- general of health in 1995. Action and Reaction: Efforts Elsewhere Where Cape Town had failed, Johannesburg dared l o tread. In March 1991 the Johannesburg City Council banned smoking in take-away restaurants POLITICAL CHANGE IN SOUTH AFRICA 127 and required that 60 percent of seating in all other eateries be reserved for nonsmokers (Burgers 1991). The council faced strong opposition from pro-tobacco groups such as the Johannesburg Chamber of Commerce (Woodgate 1991), but it stood by its decision, arguing that council mem- bers would rather have "egg on their faces than death on their con- sciences" (Nevill and Gill 1991). Steps had also been taken in the Eastern Cape Province, where the medical officer of Port Elizabeth had banned smoking in prominent pub- lic buildings in the city. Even private companies started to act: many declared their cafeterias and boardrooms smoke-free areas and encour- aged smoking executives to attend subsidized quit-smoking courses (Bar- rett 1989). These events, particularly those in Johannesburg, prompted Popkiss to launch a new offensive against smoking in 1992, asserting that Cape Town should match the bylaw passed in Johannesburg. The Cape Town medical officer was convinced that his new recommendations would fare better than previous ones had, since they were shorter, simpler, and easier to understand. For the second time, however, his proposals came under heavy attack from pro-tobacco lobby groups, and once again the Cape Province administrator refused to pass the bylaw. A Turning Point With the second failure to pass a no-smoking bylaw, prospects for legisla- tion in the Cape Province seemed dim. On the national level, however, the appointment of the country's first woman health minister provided a gleam of hope. Dr. Rina Venter may not have been a pro-control advocate when she assumed office, but she was an open-minded social worker with sympathy for nonsmokers who had to suffer from passive smoking (Saloojee 1993a). Perhaps her most important quality was that she was a skilled politician and person of integrity who was prepared to fight for legislation she believed in. Yussuf Saloojee remarked that "the spark that may have served to focus the mind of the minister on the issue" came in 1991, in the debate on her first health budget (Saloojee 1993a). During the discussion, an opposition member of Parliament, Carole Charlewood, criticized the government, accusing it of "protecting the vested interests of the power- ful tobacco industry, and not the people of the country." Charlewood's attack was based on the 1988 report of the Medical Research Council, "Smoking and Health in South Africa: The Need for Action" (Yach and Townsend 1988), which argued that "the costs of the tobacco industry to society outweighed its benefits" (Wilkins 2000) and advocated strong measures to discourage smoking. 128 MIIA MALAN ANi) ROSEMARY LEAVER Venter knew that, other than low-key, low-budget educational cam- paigns, the government had very ]ittle with which to defend itself against Charlewood's accusations. In her reply the health minister therefore promised to look into the possibilit)y of tobacco control legislation. She later said that "she regarded the matter as sufficiently important to make the decision there and then without -iaving first consulted with her cabi- net colleagues" (Saloojee 2002). According to Saloojee, that moment was the turning point in the administration's approach t0 tobacco control: "It was a vital public commitment, and the f1rst signal of new thinking on this issue at the highest levels of government." Building Support Venter was well aware of her party's vested interests, and she recognized that it would be unrealistic to expect full support for her plans. She also knew that one minister, however determined, was "not going to disperse the smoke ring alone" (Perlman 1991a). The outcorre of her undertaking would depend crucially on how much support the health department got from the rest of the government. It was not only her party's well-oiled links with the industry that seemed to stand in her wvay: the state president and many of his colleagues were chain-srnokers. In fact, when F. W. de Klerk was asked to observe NTo Tobacco Day by not smoking, his office replied that his schedule that day was too stressfu] for him tc do without (Perlman 1991a). But despite being a heavy smoker, de Kierk knew that the addiction was harmful, and he supported moderate measuares to discourage smoking. The tobacco industry was a major source of taxes, export revenue, and jobs. According to Perlman (1991a), in 1990 the industry generated 988 mil- lion South African rand in taxes, employed over 60,000 people, and spent nearly 90 million rand on advertising.1 There were, furthermore, several major tobacco-sponsored sports even-ts such as Ben,on & Hedges cricket and the Rothmans July Handicap, the prenrmier horse race. But Venter had a strategy. Shortly after her announcement, one of the country's most influential antitobacco alliances, the Tobacco Action Group (TAG), sought a meeting with her. TAG consisted of three large, highly vocal lobbying organizations: the Heart Foundation of Southern Africa, the Cancer Association of South Africa, and the National Council Against Smoking. TAG was highly effective in using "public fora and the media to warn the public against tLie dangers of tDbacco, to call on the government to introduce effective counter measures, and to discredit the industry's claims about their product and the importance of their indus- 1. In 1991, 2.5 South African rand =1 U.S. dollar. POLITICAL CHANGE IN SOUTH AFRICA 129 try" (van Walbeek 2002a). Venter knew that she would not be able to steer a tobacco control bill through Parliament without positive media cover- age and outside support. She therefore made a pact with the alliance: she would push for a draft bill from inside if TAG would see to matters out- side the legislature (Saloojee 1993a). Saloojee later remarked that Venter "stood by her word throughout this process" (Saloojee 2002). The agreement meant that the health minister did not have to spend time campaigning for favorable media coverage and backing beyond Par- liament: experts were going to do it for her. This plan fit well with the changing role tobacco-control lobbyists saw for themselves during the early 1990s: "Rather than lobbying the policymakers, they were working with the policymakers in publicizing the positive aspects of the proposed tobacco measures" (van Walbeek 2002a). But however skilled TAG was, it did not face an easy task. The coun- try's two most powerful media institutions at the time, the South African Broadcasting Corporation (SABC) and Nasionale Pers, had close ties with the tobacco industry and were in many respects government controlled. Nasionale Pers owned almost all Afrikaans newspapers and had sold a considerable proportion of its company shares to Rembrandt (Perlman 1991a). The SABC received substantial government subsidies and claimed that many of its radio stations could not survive without cigarette adver- tisements (Saloojee 1993a). When the NCAS produced its first antismoking commercial, which it regarded as "a first step towards educating the public to stop being seduced by cigarette advertising" (Levy 1991a), the SABC refused to broadcast it. The corporation conceded that it had a gentlemen's agree- ment with the cigarette companies, saying that "because the tobacco industry had voluntarily undertaken not to advertise tobacco products on TV, it would be unfair to accept anti-smoking ads" (Levy 1991b). In stark contrast with other print media companies, Nasionale Pers was (unsur- prisingly) reluctant to place the advertisement and coyly said it wanted to look at the copy before deciding. The visual broadcast version of the com- mercial, entitled "Smoky Conversation," showed six young people pic- nicking and smoking in an idyllic setting while talking about the dangers of their addiction. It was to be shown in all major cinemas for two weeks in April that year, but at a high and unusual cost: Cinemark, one of the country's biggest cinema chains, waived its usual policy of presenting public service messages gratis and charged for showing it. The reason was clear-fear of losing tobacco advertising, as almost a third of all cinema ads were for cigarettes (Perlman 1991a). Saloojee dismissed the SABC's stance as "rubbish." Tobacco was "unde- niably the largest preventable cause of death and the NCAS had a right and a duty to inform the public about its dangers using all available media." 130 NMIA MALAN AN]) ROSEMARY LEAVER The industry declined to cornmernt, arguing that "smoking was too emo- tionally loaded to be put into pers-pective in a single paragraph" (East Lon- don Daily Dispatcch 1991). Instead, it released a leaflel, "Common Sense in Smoking-Personal Choice and Moderation the Key" (Perlman 1991a), which asserted that allegations against smoking were based on heated reac- tions rather than factual foundations. One paragraph stated, "The industry does not react to points of view which are made merely for the sake of gen- erating publicity, but prefers to put its own point of view to those people who are mindful of their health and t:ie co ivenience of others and who are prepared to make allowances for other forms of enjovment." When the industry called for private talks vith the minister, it became apparent that it had more than the distributici of pamphlets planned: it was going to spend sizable amounts to fy in three international consul- tants to persuade the minister that legislation was unnecessary (Saloojee 1993a). Venter agreed to the meeting provi ded that she could involve local tobacco control advocates, including TAG, the Medical Research Council, and an economist from the University of Cape Town. Two years later, dur- ing the proceedings of the Extended Public Committee, she described the encounter: "We spent an entire afternoon, from two o'clock to five o'clock, on this matter. These people gave an elucidation of research which in their opinion, as they interpreted it, indicated that tobacco smoke was not at all harmful" (Hansard 1993). Saloojee (2002) recalls an apprehensiveness within the tobacco control group, some of whose members "felt like the 'B' tearm, and were slightly intimidated by the international experts." But ir the end, the South Africans were the ones who convinced the minister. At the conclusion of the meeting, Venter "unequivocally stated that she was going to proceed with legislation because it was her department's duty to warn smokers of the risks of smoking and to prctect the rights of non-smokers without infringing on the rights of smokers" (Saloojee 1993a). Yet again, there was a strategy involved. Yach recalled that the minister instructed us to be on our wAorst possiile behavior, which was quite pleasant to be. I'm pretty sure they [hought they were coming into a developing country where the knowlecige base about the tobacco industry's behavior was poor. But we had already been fully briefed- through our links with international colleagues-on everybody who was going to be before us. We knew all their arguments and that they could be countered easily. (Yach 2002) Venter later described it as a clay of great satisfaction: If there has been one day in my life on which I havae been proud of our scientists, it was that day. Not only did they testify to the thoroughness POLITICAL CHANGE IN SOUTH AFRICA 131 with which they do research, but also demonstrated that they could hold their own in a debate on an international level in which arguments were being advanced in regard to the harmfulness or otherwise to one's health of tobacco smoke. (Hansard 1993) Saloojee believed "the industry's ability to buy expensive foreign lobby- ing consultants" had turned into a liability: "Nationalism became an advocacy tool. It was a matter of national pride that the home-grown sci- entists had put the foreign experts in their places" (Saloojee 1993a). The Road to Legislation Months later in 1991, Venter introduced the Control of Smoking and Adver- tising of Tobacco Products Draft Bill. The proposed legislation would give her powers to bar or limit smoking in certain public places and make it an offense to sell cigarettes to anyone under 16. But the real sting was in the changes the minister wanted to make to the advertising code for tobacco products: visual commercials would be required to carry a rotating health warning, and broadcast versions would have to include the phrase "smok- ing is a health risk" in a voice similar to that of the main presenter of the advertisement (Perlman 1991a). Advertisements would not be allowed to: * Depict any woman of childbearing age as being associated with smoking * Imply that smoking is associated with success in sports * Imply that the use of tobacco products is a sign or proof of manliness, courage, or daring or enhances feminine charm. Restrictions were also to be placed on tobacco companies' sponsorship of sporting events and any other activities implicitly associated with health, success, or youth. Together, these restrictions called almost every cigarette advertisement in South Africa into question. Tobacco control lobby groups welcomed the proposal but pointed out that a multifaceted approach was needed. The National Council Against Smoking suggested a "comprehensive anti-smoking program centered around increased taxes on tobacco products" (Leaver 2002). The Medical Research Council reiterated this plea, expressing concern about the increased incidence of smoking among teenagers in poorer, predomi- nantly black communities (Medicine Today 1991). The tobacco industry chose not to comment. Stumbling Blocks Venter's draft legislation was to be published in the Gazette on June 28, 1991. (All proposed legislation must be published in the Gazette before 132 V IA MALAN AND ROSEMARY LEAVER being introduced in Parliament.) [t was at this point that the "vested inter- ests" that Member of Parliament Carole Charlewood had commented on in 1991 became apparent: a day after Vent2r had her "triumphant" meet- ing with the tobacco industry representatives and local antismoking advocates, the government delayed her p]ans to publish the proposals. The state maintained that the delay would allowv for "the incorporation of a few new ideas" and would give the minister dime to review them (Perl- man 1991b). Authorities promised that the poslponement would be min- imal. But two months later, in September 1991, the health department announced that the draft Legislation would only be submitted in the fol- lowing year's parliamentary session. In March 1992 the proposed law reemerged, this time as the Tobacco Products Control Bill.. TAG immediately organized a workshop to broaden support for the bill, inviting professio nal, labor, and community associations. Each organization was asked to issue a public statement on smoking and health and to make reoresentations irt favor of the legisla- tion. Through this lobbying process, 86 percent of the submissions received by the Department of National Health and Population Develop- ment were in support of the proposals (Saloojee 1993a). The bill's most significant opponents were the Scuth African Business Institute and the SABC. TAG felt that there was nol much it could do to influence the Business Institute but that "the opposition of the SABC could prove a major impediment" (Saloojee 1993a). The SABC asked for radio to be exempt from broadcasting health warnings, as some of its radio stations received up to a thLrd of their revenue from cigarette com- mercials. It argued that the industry would shift its advertising from radio to billboards and print media, where it could more easily disguise warn- ings. The SABC's case was strongly argued, and research had shown that many illiterate people identified cigarettes by package design and would not understand printed health messages. A cornprornise was reached that exempted radio stations providecL that they set aside a pro rata amount of free time for broadcasting health messages. The tobacco industry yet again reFused to comment publicly. It stuck to its "private approach," with the Tobacco Institute cf South Africa (TISA) sending representatives directly to the health minis ter (Leaver 2002). ln June 1992 the health depart-ment once again announced that the bill was unlikely to come before Parliament until the next year. Although Parliament was due to adjourn later tha. month, the bill was not on the order paper, nor had it been referred to the Joint Committee on Health for consideration. A health departrment spokesperson said the minister was still discussing the bill with interested parties but strongly denied rumors that the delay was the result of press ure from tobacco organiza- tions. It later emerged that TISA had been given the opportunity to sub- POLITICAL CHANGE IN SOUTHI AFRICA 133 mit further representations to the health minister and had met with her earlier that month. Many of Venter's fellow National Party ministers were in disagreement with the bill. For example, the minister of agriculture criticized what he viewed as "punitive measures " against smokers and saw it as "fitting that the industry had simultaneously tried to improve its position and combat the anti-tobacco lobby by forming the Tobacco Institute of South Africa earlier that year" (Leaver 2002). He emphasized how much rev- enue the industry provided to the state. Antismoking advocates criticized the minister's failure to mention the costs of tobacco use in the form of disease, lost productivity, and medical expenses to the state, which, a widely publicized Medical Research Council report argued, "far out- weighed the benefits of smoking, defined as the sum of tax revenue accru- ing to government and income earned by employees in the tobacco indus- try" (Leaver 2002). Health advocates were also greatly concemed about the delays in the legislation, knowing that the industry would do everything in its power to use the postponements to stop it from being passed. Saloojee remarked that "it was difficult to understand the delay in the bill's publication when the express purpose of publication was to elicit comment" (Cape Timies 1991). Political Supportfrom the New Government One important factor that worked against the tobacco industry was South Africa's changing political landscape. By 1992, the country was in transi- tion; its first democratic elections were only two years away, and Nelson Mandela, the country's president-in-waiting and one of the leaders of the antiapartheid liberation movement, the ANC, had gained considerable support after being released from prison in 1990. Two months after the draft bill was finally published for comment, on World No Tobacco Day, May 31, 1992, Mandela made his stance on smok- ing clear when he declared his total support for the bill, appealing to all South Africans to back antitobacco campaigns. Thereafter, the tobacco industry's strategy changed noticeably. Saloojee (1993a) observed that it moved from "trying to defeat the bill, to simply weakening it" and spec- ulated that, after hearing Mandela's statement, the industry realized that killing the bill could result in even stronger legislation from a future ANC government. These conjectures seemed to be confirmed when, shortly after Mandela's statement, cigarette companies complained to the minis- ter that the issue had been politicized, "and that while they could trust the present government, they were not too sure about the next." Another watershed event was the international conference on tobacco use and its control in Africa that Yach and other members of the Medical Research 134 MIA MALAN AND ROSEMARY LEAVER Figure 6.1. De Klerk Prepares to Take Leave of Power and the Tobacco Control Debate: A Cartoonist's Perspective. "It would be better for all if youi stopped smoking." State P:-esident de Klerk ivas known to be a heavy smoker lbut supported weak tobacco control efforts. Future president Mandela had made a strong s atement of support for the tobacco control bill, which de Klerk's governmen: was delaying. So rctc Cape Tin1ies, June 2, 1992. Council had long been planning and that fina Lly took place in Harare, Zim- babwe, in 1993. Dr. Nkosazana Zuma, who h bd recently been hired by the Medical Research Council and was soon to become the first health minister of the new South African governme it, gave the opening speech in her capac- ity as a representative of the ANC. She macde clear her personal commitment, and her party's comnLitment, to strong ef7orts to reduce tobacco use in South Africa. The more than 100 conference participants included a large South African delegation, people frorm) about 35 other countries, several notable international experts in tobacco control, and a smr 11 huddle of representa- tives of tobacco growers (Chapman and others 1994). Debates i'1 Paerliainent In Parliament, which still consisted mostly of National Party members, the tobacco industry maintained its snrong .nfluence. The Tobacco Prod- POLITICAL CHANGE IN SOUTH AFRICA 135 ucts Control Act was tabled in March 1993, after a delay of more than a year. During the interim, TAG was assured that the bill had been approved with minor changes. Although concerned that it had not been told what these revisions were, the lobbying group saw no reason to make a public issue of this. When TAG finally did get to see the tabled version, it was stunned: "The bill as introduced had been completely watered down. The clause restricting smoking in public places had disappeared, and spoken communications were exempted from the need to broadcast health warnings" (Saloojee 1993a). It was obvious that the bill had met with considerable resistance in the cabinet, as shown by a telling comment that Hemus Kriel, the minister of law and order, made before the cabinet meeting at which the bill was dis- cussed. He was heard to say loudly that Venter's proposals would never reach Parliament, as "50 percent of the cabinet plus one" would oppose it. When questioned who the "50 percent plus one" were, he replied that the state president was the 50 and he was the "one" (Saloojee 1993a). The first reaction of tobacco control advocates was to reject the weak- ened bill, but following extensive deliberations they instead decided to make representations to Parliament to try to strengthen the proposed leg- islation. TAG, the Medical Research Council, and the Johannesburg and Cape Town City Councils each asked to be allowed to give evidence to the Joint Committee on Health. Cigarette companies sent the Tobacco Insti- tute to do the same, yet again with international experts in tow. Tobacco control supporters argued that a recent Medical Research Council study had shown that the majority of the public supported tobacco control legislation, that the bill distorted the meaning of the word "advertising" because it did not include radio advertising, and that Par- liament would be subject to ridicule if it allowed the legislation to pass (Saloojee 1993a). According to the lobbyists, radio was a major issue, as it reached more South Africans than the other media. Moreover, radio, in contrast to print media, was accessible to the large part of the population that was illiterate-a market in which the industry was showing a grow- ing interest. Cigarette companies responded by releasing studies disputing the statements of the antismoking lobby. One study, by Health Buildings International, argued that "more workers complained about temperature, stuffiness, and lighting than about tobacco smoke and noise" (Perlman 1993). Other studies cast doubt on the links between smoking and disease or contended that restrictions on tobacco advertising were ineffective (Saloojee 1993b). Despite the industry's efforts, all of the health groups' recommenda- tions were accepted, with local and national authorities being given the power to restrict smoking in public places and radio commercials again 136 MIA MALAN A\ID ROSEMARY LEAVER being included in the definition of "acvert'.sements." (In certain cases, howevei; radio stations could apply for exemption from the requirement to air a health warning as part of tobacco advertisements.) The bill also outlawed the sale of cigarettes to minors and empowered the minister to prescribe the health warning and the de,ails about dangerous ingredients that were to appear on cigarette packs or in adverlisements. Satisfaction Comes with, Suc:ess On June 17, 1993, the Tobacco Products Control Act was approved by Par- liament. In Venter's own words, she had 'ultimately succeeded in arriving at a piece of legislation" that gave her "the most satisfaction of any legisla- tion" since she had had "the privilege of being a rminister." Venter made it clear that her business was health and not "pproblenms regarding the cultiva- tion of tobacco." She refrained from becoming involved in or being drawn into a discussion on the interests of tobacco producers, saying, "I really do not believe that it is a matter in which a minister of national health should participate." She also mentioned-tellingly-that she had reconciled herself "long ago that it would not be possible to take everyone along with me and to receive everyone's support for this bill.... There are too many vested interests that have to be taken into consideration" (H-nsard 1993). Measured against the international "gold standard" for tobacco control legislation, the act was mild. (For legislative "good practice," see PAHO 2002.) However, it "represented a schism between the ruling National Party government and the industry" (van Walbeek 2002a) and was the first major dent in what had been a solid wall of vested interest (Saloojee 1993a). As it turned out, it was the last piece of legislation passed by the National Party government. New Governmnent, New Regulations In April 1994 South Africa's First dernocratic e]ections were held. The ANC replaced the National Party as the ruling party. Under the new health minister, Nkosazana Zuma, the draft repulations for mandatory and explicit health warnings were published in the Gazette for comment. The regulations specified the size of health warnings required on printed advertisements and te]evised commercials, as well as on cigarette packs. The Health Ministry stated that tobaccc industry-sponsored events would not be affected by the directives, as they were examples of "indi- rect advertising" (Miller and Ramsay 1994). This loophole in the legisla- tion was subsequently exploited by the industry. Eleven different health warnings, each consisting of two parts, were listed in the regulations (Louw 1994). The fi -st part was a concise warning POLITICAL CHANGE IN SOUTH AFRICA 137 on the effects of smoking-for example, "Danger, smoking can kill you," and "Pregnant? Breastfeeding? Your smoking could harm your baby." The second part explained how and why smoking damaged health, described the benefits of quitting, and gave a telephone number that smokers who wanted to quit could call to get information and advice. (For example, "Nine out of ten patients with lung cancer are smokers. Smoking also causes cancer of the lip, mouth, voice box, food pipe and bladder. Quitting smok- ing reduces your risk of cancer. For more information or help call... .") Writ- ten advertisements only had to carry the first part of the warning, posi- tioned at the top of the advertisement and occupying 10 percent of the area of the advertisement. Another 2 percent of the area had to be dedicated to information on tar and nicotine. Cigarette packs had to carry the two-part warning, which was to occupy 15 percent of the front of the pack and 25 per- cent of the back. Antitobacco lobbyists wanted the new labeling in order to give con- sumers better information about the health hazards of smoking tobacco products, but the cigarette, advertising, and media industries objected strongly (Leaver 2002). TISA sent a submission to the government in which it argued that the regulatory health warnings were unconstitutional because they deprived manufacturers of constitutionally protected prop- erty rights of registered trademarks. The industry also asserted that the warnings violated the companies' right to freedom of expression by "com- pelling manufacturers to include health messages and warnings with a propagandistic character . . . without stating the source" (Leaver 2002). This argument was supported by advertisers, who said that messages without sources gave the "untenable impression that the tobacco adver- tiser is warning consumers not to use his product" (Finan1cial Mail 1994). Advertisers also claimed that there had been a lack of transparency and consultation in drawing up the draft regulations and that if the regulations became law, there would be numerous job losses in the advertising indus- try because the tobacco industry would end many of its contracts. The managing director of Times Media Limited, one of South Africa's leading newspaper groups, described the proposals as a form of censorship that trampled on the right to free commercial speech (de Villiers 1994a). Several newspapers and magazines argued that they stood to lose adver- tising revenue. The media's opposition was (over)stated in such melodra- matic terms as to be almost farcical: the director of Nasionale Pers, in which Rembrandt had shares, predicted a "blood bath" (de Villiers 1994a) and foresaw that the print media would lose millions in revenue and be "para- lyzed" (Leaver 2002). The Medical Research Council refuted these absurd claims, quoting a study by the council which had found that in the "10 most popular South African magazines, each with a circulation of over 100,000, tobacco accounted for less than 10% of total adspend" (Leaver 2002). 138 MIIA IVIALAN ANi) ROSEMARY LEAVER The one significant concession was that in August 1994 the health min- ister exempted radio stations from the advertising regulations for one year. Radio stations had argued that they would be hard hit by the new regulations and could lose millions in tobacco advertising revenues (de Villiers 1994a, 1994b). They said they needed time to adjust, since a sud- den drop in their revenues might force them to close down broadcasts to isolated and illiterate rural groups, for whom they were a vital source of information and entertainment. For their part, the Independent Broad- casters Association agreed that "the proceeds of five advertising spots per day per radio station which carries tobacco adverts he given to the [health department] for running a campaign aimed at warring people about the dangers of smoking" (de Villiers 1994a, 1994b). Four months later, in December 1994, the regulations governing the display of health warnings on tobacco products and in advertisements were published in the Gazette under the Tobacco Products Control Act of 1993. Enforcement would begin only after several months, to give the tobacco industry time to use up stocks oir existing packaging materials. After the legislation was "gazetted," TISA complained that it had not been consulted (Leaver 2002). It had, in fact, voiced its views on several occasions but had not prevailed against the coimterarguments and factual evidence presented by the public health groups, which argued that the measures were important for pro tecting and p romo ing public health and that the actual economic losses would be trifling, in contrast to the exag- gerated claims of those seeking to protect their vested interests. Implications for the Provinces: New Hope for Cape Town The implementation of the Tobacco Products Conlrol Act in 1994 was a significant development for municipalities because it granted them the right to apply to the health department to promulgate their own regula- tions controlling smoking. This was particularly good news for Cape Town because it meant that the administrator no longer had veto power over antismoking measures in the city. Michael Popkiss, Cape Town's chief medical officer, was quick to apply for these powers. Within four months the Cape Town City Council had tabled draft regulations to restrict smoking in virtually all public places. Specifically, the municipal regulations prohibited smoking in 80 percent of every city restaurant and bannecd smoking in shopping malls, theaters, cinemas, and all municipal buildings. Public transport, such as trains, buses, and taxis, was also out of bounds for srnoking (Oliver 1994). A fur- ther stipulation was that any room in which smolPrice (real, 1995 base) ., 400 -- ~*\ / Excise tax < 300 - : (nominal) o 200 - - E Excise tax (real)-X U) ~~~1995 base) 100 1961 1975 1982 1985 1988 1991 1994 1997 2000 Source: Van Walbeek (2002a). discriminatory. Rembrandt alleged that smuggled cigarette brands had already started entering South Africa as a resLIt of the new "sin taxes" on tobacco (Citizeni 1994). The company's new chair, Johann Rupert (Anton Rupert's son) claimed that smuggled brancs were undercutting local ones and that this could backfire on the governmert by negatively affect- ing state revenues (Leaver 2002). According to van Walbeek (2002a), Rupert's claims were misleading, and deliberately so: if he could per- suade the government that cigarette smuggling was increasing as a result of the high taxes, he might also persuade it that the solution would be to reduce the tax. Only in 1997 was one of the groups finally satisfied, when the new finance minister, Trevor Manuel, announced a tax rate of 50 percent of the retail selling price of cigarettes.. after intensive lcbbying by Zuma and antismoking groups. Saloojee asserted that the increase would result in 400,000 fewer smokers and an extra 620 mnillion rand in new revenue for the government, which "could be used to employ more customs and excise officials and tighten border controls" (cited in Singh 1997). The tobacco industry was infuriated by the increase, arguing that thousands of the country's farmworkers wouild lose t:heir jobs. Economists at the University of Cape Town challenged this assertion, pointing out that new jobs would be created to satisfy increased clemand for other goods and POLITICAL CHANGE IN SOUTH AFRICA 143 services as people switched their expenditures from cigarettes to other items. Manuel has since then held firm to his policy and has maintained annual tobacco tax increases of about 50 percent in his budgets (van Wal- beek 2002b). The Strugglefor Compliance In a parliamentary address in October 1996, Zuma accused tobacco compa- nies of ignoring laws requiring the display of health warnings on cigarette packs. The minister warned that "if cigarette companies continued to refuse to comply with the law, her departmrent would respond by banning tobacco advertising" (Leaver 2002). Johann Rupert responded by publishing a full- page open letter to Zuma in the Sunday newspapers saying that the absence of health warnings on certain brands could be blamed on cheaper smuggled goods which had entered South Africa illegally. He alleged that this was the consequence of high tobacco taxes that his company had warned the minis- ter about. In a statement in reply to Rupert's open letter, the minister vowed to intensify her campaign against tobacco, saying, "Responding to individ- uals is not really our priority at this stage. We are more concerned with the health of the nation" (Leaver 2002). Meanwhile, cigarette companies and broadcasters took advantage of a loophole in the advertising restrictions in the Tobacco Products Control Act. The act considered sports sponsorships an indirect form of advertis- ing, thus exempting such events from having to display health warnings. The SABC showed Benson & Hedges logos on television during an inter- national cricket match, maintaining that displaying a logo, however prominent, did not constitute advertising (Rulashe 1996). Both the SABC and the tobacco company were strongly criticized, and Zuma threatened to take serious action against companies that were considering "taking advantage of loopholes" in the future (Leaver 2002; see also figure 6.3). The minister's unwavering political support for tobacco control and her outspoken behavior left her rather exposed. The tobacco industry spent sizable amounts on generating research supporting its position or trying to cast doubts on the arguments and evidence put forward by the public health groups (Wilkins 2000). Clearly, the industry could outspend the groups that were lobbying for tobacco control. In 1996 an important new partner joined the tobacco control lobby when a number of professional economists entered the debate and set up the Economics of Tobacco Control in South Africa (ETCSA) Project. The project, established at the Applied Fiscal Research Centre of the Univer- sity of Cape Town with funding from the International Tobacco Initiative (now Research for International Tobacco Control, a secretariat at the International Development Research Centre in Canada), aimed to make 144 MIA IVL[LAI AND ROSEMARY LEAVER Figure 6.3. Zu ma versus Rupert: A Cartoconist's View " VT, WJ Ut- Health Minister Zuma prepares to ob iterate tobacco company chair Rupert's opposition to tobacco control. The "wnti tg on the wall" is a swt of antismoking statements. Sooirce: The Star, October 22 1996. available to the government and to others sound anld accessible informa- tion on tobacco control by systematicallv researching economic issues and providing facts that contradicted the false -laims of the tobacco lobby (Abedian 2002). The ETCSA Project's researchr firdings countered many of the indus- try's claims and were well publicized. Accorcing to Iraj Abedian, ETCSA's project leader at the time, the findintgs provided important evi- dence to support Zuma's anti-tcbacco policies and the tax increases. One of the most significant conclusions was that a rise in tobacco excise taxes would increase government revenues, not reduce total revenues as the tobacco lobby claimed. In fact, the research demonstrated that the gov- ernment was earning much less than it could frorn tobacco taxes: it was estimated that had the state attempted to maximii'e its revenue from cig- arettes, excise receipts could have been 129 percent higher in 1995 than they actually were (see figure 6.4). Other findings were that job losses in tobacco-related sectors would bh rmore than compensated for by job gains in other sectors, since consumers would spend their money on other POLITICAL CHANGE IN SOUTH AFRICA 145 Figure 6.4. Potential and Actual Cigarette Tax Revenues (Excise and Sales Taxes Combined), South Africa, 1971-2000 1971 ' F _ ' Potential total tax revenues 197 a _ , , :2 ~Actual total tax revenues 1973 a I'ZgE S t _____Ri a' __ _ _ 1974 3 1976 1976 1977 t: oq u "wm= g 1978 1979 1980 * 19B1 fiSRS>Xe 5 qa 1989 1990 1991 1992 1993 1994 -S s: '-*Eu : 1995 i 1996 an albeck P 0a). 1997 1998 1999 ______ 2000 0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 5,000 Millions of rand (1995 prices) Sotirce: Van Walbeek (2002a). 146 M11,\ vl \1A\1 ') ROSEMARY LFAVER goods and services, and that South Africa did riot have a significant ciga- rette smuggling problem (van XVa [be k 2022a). Evidence that the government's obacco control policy was proving effective emerged in May 1996, wvheii a surve)' foun(d that the proportion of adults who were currently smokers had declined from 34 percent in February 1995 to 32 percent a year later. 1P also re\ eailed that more than 8 out of 10 adults viewed health warnings ort cigarette packs as helpful and informative. Ihese findings convinced the he.llth minister "that manda- tory health warnings on tobacco packaging hadi proven to be an effective tool in educating the public about the dangers of smaking" (Leaver 2002). An anecdote illustrates the power of these warn ngs For certain con- sumers: some shopkeepers reporfed that slhor[ly after the warnings were introduced, some customers asked for thc "old" cigarettes rather than the "new" ones, pointing to the warnings an-d saymng that the new ones would cause them to get sick. These customers assumed that the product had changed, necessitating the new warnit-tgs (Saloojee 2002). Within a year after taking office, Nelson Maandela was awvarded twvo no- smoking medals: one in August 1994 bay the Commonwealth Games Council and another in May 1995 by thie World Health Organization (WHO). On accepting the latter award on his iehalf in Vancouver, Canada, Minister of I Health Zuma sa id lhat millions of children faced pre- mature death from diseases caLused by toba1cco, and that "this preventable tragedy must be averted" (Strachan 1995). 1999 Legislation- In January 1998 the health min,ster announced that a Tobacco Control Amendment Bill wou-ld be tabled in Parliament that year. Initially, Zurna gave little indication of precisely what c ianges it would entail. Address- ing a tobacco conference in Februarv, ho'A'e\er, she hinted at "an outright ban on advertising, sponsorships a ad promotions, and raising the age at which minors could legally buy cigarettes to 18" (Leaver 2002). Six months after the minister had arnoui-tced her plans, the Tobacco Products Control Amendment Bil was unanimoLusly approved by the cabinet. Among other provisions, it outlawec smoking in enclosed public spaces (including workplaces), banned tobacao adv ertising and sponsor- ship, and made it illegal for anyone to sell cigarettes without the pre- scribed health warnings on packs (Soal 1998a). The cigarette manufacturing industry slammed the health department for tabling a "draconian- bill out of [he blue eight weeks before Parliament closes" (Leaver 2002). Many opposition patties cgreed, remarking that "the Zuma Bulldozer is clearly in overclrive" (Stuart 1998). The industry complained that the tobacco control lobby had benefited from many POLITICA1. CfA.N\CF IN SouiTEl AFRICA 147 months of access during the bill's drafting process, whereas the tobacco industry had been totally excluded from the process. Cigarette compa- nies, alonyg with adverLising and freedom of expression organizations, argued that the legislation was a gross violation of the right to freedom of speech. But Zuma had no interest in modifying the proposals in response to pressure from the industry, and she threatened to take the battle to the country's highest court (Khan 1998). Zuma even went a step further: when President Mandela asked her to consult with all relevant parties before pressing ahead, she called them together on short notice late one night. Also at the meeting were tobacco control advocates, including the Medical Research Council's Derek Yach. Yach had to counter the fears of the media companies that they would lose a large part of their income because of the ban on tobacco advertis- ing. When he reminded them that "it's better to associate with life than with death," one of the country's largest publishing houses, Caxton, which published many medical publications and also community news- papers, voluntarily withdrew its tobacco advertising in advance of the law (Yach 2002). Pro-tobacco groups had the opportunity to present arguments as well. Yach recalled that a tobacco representative asked Zuma toward the end of the meeting whether she had listened to their arguments and whether she was going to weaken the legislation as a result. She responded, "If any- thing I'll consider strengthening it, because I don't believe what you're saying" (Yach 2002). Sporting organizations did not feel comfortable with the bill, as they stood to lose sponsorship from cigarette companies. The South African tobacco industry annually spent about 40 million rand on sports events such as Winfield rugby, the Rotlimans July Handicap, the Gunston 500 (an international surfing competition), and Rothmans soccer. The Premier Soccer League was particularly concerned, as it had a 10-year contract with Rothmans worth 100 million rand that it believed would be difficult to replace (Khan 1998). Zuma's proposals also ended South Africa's Grand Prix hopes. Earlier that year the chief executive of Formula One Grand Prix had announced that South Africa was being considered as a possible host in the near future. But with the tobacco industry being the main motor racing spon- sor and competitors contractually obliged to carry their sponsors' names on their cars, the event would not be allowed in South Africa under the proposed legislation. Shortly after the bill was tabled, Formula One released its race calendar, and South Africa was notably absent. Malaysia, a country with no restrictions on tobacco advertising, had taken its place. Zuma responded to these concerns by noting that cricket had cut its ties with its tobacco sponsor (Benson & Hedges) some time earlier and 148 NMIA MALAN AN[) ROSEMARY LEAVER that the sport continued to prosper. Thne tobacco control proponents also pointed out that tobacco-sponsored events were a betrayal of the millions of youths who looked to sports to promote health, not to promote a deadly addiction (Saloojee 2002). In an attempt to alleviate some of the fears, Zuma and the sports minister discussed plans to phase in the restrictions in order to protect existing sponsorships. Ever determined, however, Zuma commented that "it will be a very short phase-in. If they have a 10-year contract, they won't Le able to finish it" (Soal 1998b). Two weeks after being approved by the cabinet, Ihe Tobacco Products Amendment Bill was published for pubic comment. Twelve days later, the tobacco industry applied for an urgent interdict to stall the legislation, citing "a lack of consultation in the bill's drafting" (Leaver 2002). Zuma was undeterred and told a journalist that "consultation does not mean we must keep consulting with them until they agree" and that she was now "more than ever determined to get the legislation through Parliament" (Soal 1998b). The applicants asked the Cape Town H gh Court to order the minister to disclose "all the information that the department had taken into account when drafting the bill" (Leaver 2002). But the case was dis- missed eight days later; the court ruled that the in -ormation was public knowledge, and Zuma proclaimed that rLo one wotuld be allowed to fili- buster the process (Baleta and Oliver 1998). Two months later, a public hearing, dubbed by some as being like "the biblical battle between David and Goliat;.," was scheduled in Parliament. More than 80 groups applied to give oral evidence over two days. Three days after the hearings, the parliamentary health committee approved the bill, to the dismay of cigarette companies. Yet again, the tobacco industry threatened to go to court, but, as in the past, the threat failed to material- ize. Instead, after a day's heated debate, the National Assembly approved the proposed legislation, with 215 votes (all from the ANC and the African Christian Party) in favor and 106 agamnst. Following approval by the National Council of P'rovinces, the bill was sent to the president for his signature. IV[andela, however, sent it back to Parliament, asking that the terms "organi !ed activity" and "public places" be more clearly defined to resolve constitutional uncertainties. The president specifically wanted clarity an v\ hether public places included private residences in which ernploy ees such as domestic work- ers performed their duties. Of particular concern vas that "people may not be able to smoke in their awn homes if they employ a domestic worker," although, on the other hand, domestic wvorkers should not be subjected to the health risk posed by secondhand smoke (Saloojee 1999). A month later, the health department riad completed the work of draft- ing amendments to the definitions n question, with "public places" cited as including workplaces but not private homes. In Mvlarch 1999 the amend- POLITICAL CHIANGE IN SOUTHi AFRICA 149 ments were approved by both the National Assembly and the National Council of Provinces. Only two provinces, the Western Cape, held by the National Party, and Kwazulu-Natal, held by the Inkatha Freedom Party, voted against the bill. The Tobacco Products Amendment Act became law on April 23, 1999, when it was published in the Gazette. (The legislation would only come into effect once a date had been set by promulgation in the Gazette.) The tobacco control lobby was extremely satisfied with the new legis- lation, with the Medical Research Council remarking that the act was "a fitting finale to Mandela's term of office because it would entrench laws that will protect children for generations to come" (Leaver 2002). The act came into effect on October 1, 2000, with the new health minister, Dr. Manto Tshabalala-Msimang, saying that she did not expect any constitu- tional challenges. After January 2001, anyone found guilty of disobeying the law (except for restaurant owners who had applied for a six months' exemption to install nonsmoking areas) would be liable to a fine. Zuma's tough stance against smoking was recognized by the WHO in May 1999, with the Tobacco Free World Award. The organization's director-general, Gro Harlem Brundtland, told Zuma, "We congratulate you on your work-you have strengthened our hands and given hope to many countries" (WHO 1999). Back in South Africa, the tobacco and advertising industries continued their exaggerated, even absurd, rhetoric, comparing the new legislation to laws enacted by Nazi Germany and referring to Zuma as a "new Hitler." The minister replied, "I'm getting used to the names by now. What is important is whether we are transforming society for the better, and I think we are" (Soal 1998b). Conclusion Derek Yach believes there is an important lesson to be learned from South Africa's achievements: "You need the right combination of science, evi- dence and politics to succeed. If you have one without the other, you don't see action." He believes that South Africa has had an effective mix of basic science, political commitment, and the ability to move ahead (Yach 2002). Despite the significant opposition encountered, South Africa now has one of the most comprehensive tobacco control policies in the world. Van Walbeek (2002b) noted that "whiLe the health impact of the change of smoking patterns will only be felt in years to come, the short-term mea- surable outcomes suggest that the South African government's tobacco control policy is proving successful: between 1993 and 2000, total tobacco consumption decreased by about 26% . . . per capita consumption 150 MVIA MALAN. AND ROSEMARY LEAVER Figure 6.5. Real Cigarette Prices and Smoking Prevalence by Income Group, South Africa, 1993-2000 Income (rands) 1-899 40 900-3,999 - 600 o 4,000 + real price 550 e35 500 _ 25- =< >~~~~~~~~~~. 2~~50 CL a)~~~~~~~~~~~~~~~~~~~~~~~~~~~L 3 30 -00 0) 3 350 19 25 300 250 E20 200 C 150 15 -I----*00 1993 1994 1995 1995 1997 1998 1999 2000 Soiurce: Van Walbeek (2002a). decreased by 37% ... the percent of adults who smoke decreased from 33% to 27%, with the biggest decreases be Lng seen in low income groups . .. and the percent of young people agecL 16 to 24 who smoke has decreased sig- nificantly from 24% to 19%." Figure 6.5 clearly shows the decline in con- sumption across all income groups and the much faster and deeper decrease in smoking in the lower-income groups. Although the degree of compliance wi:h antismoking legislation seems to be high, some say more can be done. Saloojee points out that despite sig- nificant increases in tobacco taxes, cigarettes in South Africa are still very cheap in comparison with other countries and that they continue to be affordable, particularly for young people. 'See figure 3.2, in chapter 3 in this volume, which compares cigarette prices across a number of countries.) He adds that it is almost impossible to institute legal action for medical dam- ages against cigarette companies without having "sizable amounts of money." Saloojee also points out that sorne countries, such as Canada and Brazil, now require large pictorial warnings on tobacco products-"some- thing which South Africa needs to consider if we want to keep up with leading tobacco control countries in the world" (Saloojee 2002). POLITICAL CHANGE IN SOUTIH AFRICA 151 References Abedian, I. 2002. Personal comrnmunication, June 3. Baleta, A., and L. Oliver. 1998. "Zuma Snuffs Giants: Tobacco War Victory." The Independent on Saturday, Sept. 5. Barrett, C. 1989. "Smoke-Free Zones: PE Takes a Stand." Weekend Post, Oct. 14. Bateman, C. 1989a. "Civic Uproar over Smoking: Leading Lights Defend Pop- kiss." Argus, March. . 1989b. "City's Smoke Ban Angers Anton Rupert." Argus, April. Burgers, L. 1991. "Clampdown on Puffing in Restaurants." The Star, March 27. Cape Argus. 1988. "Smoking Restricted in City Restaurants, Adverts Banned." March 28. . 1989a. "Anton Rupert Sends Retort over No-Smoking Issue." March. . 1989b. "Medical Campus Smoking Ban." March. Cape Times. 1991. "Did Tobacco Chiefs Stub Curbs Plan?" May 7. . 1995a. "City Dictatorship on Smoking." April 3. . 1995b. "Seven Million Can't Be Extinguished." June 1. Cape Town Chamber of Commerce. 1990. "Smoking Ban Reversed." Cape Town Chamber of Commerce Weekly Bulletin, March. Chapman, S., D. Yach, Y. Saloojee, and D. Simpson. 1994. "All Africa Conference on Tobacco Control." British Medical Journal 308: 189-91. Citizen. 1994. "High Excise Increases Cigarette Smuggling." July 28. Dennehy, P. 1989a. "Council Curbs Employees Smoking." Cape Times, March 31. . 1989b. "City Smoke Ban Vetoed." Cape Times, April. de Villiers, L. 1994a. "Ad Industry Comes out Smoking." Weekend Star, Aug. 20-21. . 1994b. "SABC Radio Gets Tobacco Reprieve." The Sta,; Aug. 26. Doman, A. 1989a. "Restaurant Smoking Ban Backed by Health Council." Argus, March 30. - 1989b. "Restaurateurs Give Council Week to Scrap Ban." Argus, July 28. - 1989c. "Restaurant Owners to Fight Ban on Smoking." Arguis, July 27. East London Daily Dispatch. 1991. "SABC Refuses to Screen Anti-Smoking Advert." May 4. Financial Mail. 1994. "Putting out Fires." Sept. 2. Fothergill, M. 1991. "Smoking Comes under Fire." Businiess Day, April 8. Hansard. 1993. Debates of Parliament, no. 19, Republic of South Africa. Fifth Session-Ninth Parliament. June 1-4: 10105-58. Hotel and Caterer. 1995. "Separate-Then Ventilate!" Nov., 33-37. Jackman, T. 1995. "Blow Smoke in the Face of Insanity." Cape Tines, April 7. Khan, F. 1998. "Smoking Ad Row Flares." Natal Daily News, July 31. Leaver, R. 2002. "Tobacco Control Policy in South Africa as Seen through the Eyes of the Media." In C. van Walbeek, The Economics of Tobacco Control in South Africa. University of Cape Town. Levy, T. 1991a. "Fired-up Ads from the Anti-Smoking Gun." Business Day, April 4. _. 1991b. "Anti-Smoking Ads Banned by SABC TV." Buisiness Day, April 5. Louw, C. 1994. "Warning: The Regulation of Tobacco Ads Can Be Hazardous." Weekly Mail and Guardian, July 8. 152 VIIA MIALA'J AN i) ROSEMARY LEAVER Medicinie Today. 1991. "Smoking Ad Laws Do Not Go Far Enough-MRC." June 27. Miller, S., and R. Ramsay. 1994. "Smoking Risk Ads Become Law Soon." Natal Daily News, June 22. Morris, M. 1989. "Rupert Warns of 'Mafia' Tob3cco ',woop." Argus, March 9. Natal Daily News. 1991. "Local Media Drawn into Anti-Smoking Ads." April. . 1995. "No Smoking Ignored." April 3. Nevill, G., and G. Gill. 1991. "Smoking Ban out of Puff?" Cape Timles, March 28. Oliver, L. 1994. "Council to Stub Smoking fronm Er closed Public Places." Argus, Sept. 7. PAHO (Pan American Health Organizar:ion). 2002. "Dev-loping Legislation for Tobacco Control." Washington, D.C. Available at . Parker, W. 1995. "Smokers Meekly Accept Cape Town's Ban " Butsiniess Day, April 25. RE. Advertiser. 1999. "Zuma Gets Tobacco Free World Awz rd." May 18. Perlman, J. 1991a. "Rina Venter Kicks the Butts." Wcekly lvail, June 27. - 1991b. "Anti-Tobacco Lobby Comes out Smoking as State Stalls." Weekly Mail, July 12. - 1993. "Better Air or Smoking Ban?" The Star, Jan. 30. Popkiss, M. 1995. "Clearing up the Confision." Cape Times, April 25. Pretoria News. 1994. "Public Smoke Ban on Cards." May 3 L. Republikeini. 1994. "SA Government WF,nts to Avoid S noking" (in Afrikaans). June 1. Rulashe, L. 1996. "Plan to Stub out Smoking 'P'mps."' Suiday Timnes, Jan. 14. Saloojee, Y. 1993a. "Tobacco Control: A Case Study (South Africa)." In Proceedings of the All Africa Conference on7 Tobacco awid Health. 1 November 1993, Harare, Zinmbabwe. . 1993b. "A Misinformation Industry." Butsziness Day, Oct. 29. . 1999. Statement on the referral of the tobacco bill to Parliament (news release), Jan. 22. Tobacco Action Group. . 2002. Personal communication. Singh, P. 1997. "Anti-Smokers Warn against Pressure from Tobacco Industry." Thle Star, March 31. Smith, D. 1995. "Waterfront Joins Battle." Cape Times, Oct. 30. Soal, J. 1998a. "Government's Tough Nvew Curbs on Smok ng." Cape Tiles, July 15. . 1998b. "Every Which Way, Smokers Are on the Run." The Star, Aug. 7. South Af'ican Medical Joulrnal. 1963. "Cigarettes ancd Smoking" (editorial), 37 (39): 974-75. Steenkamp, W. 1994. "Tobacco Giants Hit hack at 'Tot3l Onslaught' on Ads." Argus, June 4. Strachan, K. 1995. "No-Smoking Bylaw -las Guild Fumin,." Butsiniess Day, Oct. 10. Stuart, B. 1998. "Zuma Accused of Billctozing Bills " Cit _:e1, Sept. 5. van Walbeek, C. 2002a. The Economnics of Tobacco Co, itrot io Souith Afr-ica. University of Cape Town. . 2002b. Personal communicatio'i, May 17. Wilkins, N. 2000. "The Economics of Tobacco Control in South Africa: Lessons for Tobacco Control Toolkit Development." March 33-31. Briefing note pre- pared for the WHO meeting Dn the Develoornent of Toolkits for Tobacco Control Legislation and Econcmic Interventi ns, Ceneva. POLITICAL CHANGE IN SOUTH AFRICA 153 Woodgate, S. 1991. "Ban Goes up in Puff of Smoke." The Stanr April 24. World Health Organization. 1999. Speech by Director-General Gro Harlem Brundtland. Geneva. Yach, D. 1982. "Economic Aspects of Smoking in South Africa." Southli Af-ica;l Med- ical Journal 62: 167-70. - 2002. Personal communication. Yach, D., and G. Townsend. 1988. "Smoking and Health in South Africa: The Need for Action." Technical Report 1. April. South African Medical Research Council, Parow. Yach, D., Y. Saloojee, and D. McIntyre. 1992. "Smoking in South Africa: Health and Economic Impact." South African Medical Research Council, Cape Town. Tailoring Tobacco Control Efforts to thie Country: The Examplec of Thailand PrUkiP Vnteesatok,t The need for tobaccc control in Thailand is evident in the statistics. Among Thailand's 62 million inhabitants, fewcr than 5 percent of females smoke, but 39 percent of males c o (]National Statistics Office 1999). Although the recent economic dcwnturn and increases in cigarette taxes contributed to a decline in consump.ion from 48 billion cigarettes in 1997 to 37 billion in 2001, the toll from tobacco use is still heavy. It has been esti- mated that in 1993, 42,000 Thais died of tobacco-attributable disease (Ekplakorn, Wongkraisrithong, and Tangchareonsin 1991). Lung cancer is the number one cancer in Thai males except n the northeastern region, where endemic liver fluke disease makes liver cancer more common (Deerasamee and others 1999). Understanding Thailand's effarts to work toward successful tobacco control requires an appreciation of the complex sociocultural, political, and even personal dynamics that interact to shape Thai thinking and policymaking. These dynamics can iot be captured in a short case study and are not fully described in this deeply personal account, in which the political, social, and human factors are intimately entwined. The narrative shows that wvhile sim larities exist between the Thai experience and that of other coLtntries, the succesS of tobacco control in Thailand must also be attributed to a unique hiistorical struggle set in the rich context of Thai politics and culture (Muscat 1992). Furthermore, it is a story grounded in the rational, iterative world of medical investigation and the sometimes chaotic world of political process. Combined, these ingredients make for a fascinatinig story. The Story Begins: Small Steps ]Forward The best-known incident in tobacco control in Thailand is the well- publicized case in the late 1980s when the U.S tobacco industry used 1 L TAILORING TOBACCO CONTRO[. EFFORTS TO THE COUN FRY 155 international trade treaty provisions to force open Asian markets to foreign cigarettes. But the struggle for tobacco control in Thailand began long before that, as early as the mid-1970s. In 1974 the Thai Medical Association successfully petitioned the government to print health warnings on cigarette packages. In 1976 the National Statistics Office carried out the first national survey of smoking prevalence (now conducted every two to three years as part of the National Health and Welfare Survey), and the Bangkok Metropolitan Administration issued an ordinance banning smoking in movie theatres and buses in the city. When the World Health Organization (WHO) designated 1980 the Year of the No Smoking Campaign, the event was supported by the Thai Ministry of Public l-lealth (MOPH), the Thai Thoracic Association, the Thai Anti-Tuberculosis Association, and the Thai Heart Association. A series of public health education programs on the dangers of smoking was carried out, and the Thai Tobacco Monopoly (TTM) was success- fully lobbied to strengthen the health warning on cigarette packages. Other sporadic activities and campaigns were undertaken in the 1980s, with mixed results. In 1982 the MOPH and the WHO held the First National Conference on Tobacco or Health. Subsequently, an expert com- mittee was established to implement an ongoing campaign to reduce smoking, but because there was no secretariat or organizational support, the committee met infrequently, and little was accomplished. The National Cancer Institute listed cigarettes as a cause of cancer and carried out public education seminars. Tobacco was also included as a health issue of the noncommunicable disease division in the MOPH's Depart- ment of Medical Services. But without continuous, sustained momentum, these efforts had only limited outcomes (Supawongse 1999). When the Thai Anti-Smoking Campaign Project (TASCP) was formed in 1986, the media commented that they hoped it would not be just another "flash in the pan" that would die away (TASCP 1986). In a parallel development, in the 1980s health professionals, perceiving a need to improve the level of health advocacy in the country, established the Folk Doctors Foundation (FDF). The FDF focused on self-care, used public advocacy, and disseminated information through educational materials and the media to foster a social movement supporting care for the health of the Thai population. These efforts were early examples of the potential role of a nongovemmental organization (NGO) in tobacco control. In early 1986 Dr. Pravase Wasi, an FDF board member, respected uni- versity professor, and opinion leader, gave a presentation to the Dusit Rotary Club on tobacco and health This presentation resulted in a contri- bution of 60,000 baht (US$2,255) for tobacco control efforts. Initially, Wasi had intended to give the money to those in the MOPH who were work- ing on tobacco control. At the time, however, no special office existed for 156 P ZAKIT VATEESATOKIT this type of activity, so he decided it would be more efficient to turn the money over to the FDF to support a 3peciFic project on tobacco control. With this fund, in October 1986, Wasi launched the TASCP at Ramathi- bodi Hospital, along with anothez FIF board member, Prof. Athasit Vej- jajiva, who had just become dean et Ramath;bodi Hospital, Faculty of Medicine, Mahidol University. Dr. P'aibul Suriyawongpaisal of the Department of Community Medicine was appointed secretary of the proj- ect. The author, who was the chairrrian of the Department of Medicine, was asked to take part in the launcl- by helpintg to organize a press con- ference on the harm caused by tobacco use. Four patients with chronic obstructive lung disease were asked to sp2ak about zheir suffering, show- ing the "human face" of the epide-nic. This proved very successful in attracting press coverage. As a result, the author was recruAted to join-i the TASCP, which would serve as a focal point and pressuie proup in the lobby for tobacco control policy. One of the first tasks was to work with Dr. S'omkiat Onvimol and Laddawan Wongsriwong to produce a three-minute spot documenting the life of a patient who suffered from emphysemia and was receiving home oxygen therapy. This documentary was aired several times in 1987 and inspired several young doctors from another NGO, the Rural Doc- tors' Association (RDA), to organize a rurL in support of the antismoking cause. Dr. Choochai Supawongse, RDA chair, first developed the idea of the nationwide run with support from the VIOPH and other funding organizations. The 250 physicians and paramedics who participated ran a total of over 3,000 kilometers in the span of a week. The campaign col- lected over 6 million signatures of townspeople along the way, all urging Parliament to legislate tobacco control. The organized run was another example of sporadic, uncoordinated, but genuine and sometimes dramatic efforts by various professional groups that arose out of their personal corr,mitment to reducing harm from tobacco. Many doctors who are now senior officials trace their strong commitment to tobacco control to this event (Supawongse 1999). Building Support: Thie TASCP's Formative Years Those working for tobacco control in the early years did not fully appre- ciate the importance of having a com-prehensive and coherent strategy until 1987, when the Sixth World Conferencr on Xobacco or Health was held in Japan. That conference was an eye-opener and provided addi- tional impetus to the TASCP. Dr. Halfdan Mahler, then director general of the WHO, delivered a provocative speech about smoking mortality, describing it as equivalent to 20 jumbo jets crashing each day, or 2 million deaths per year. The diversity of the auJlence of e pidemiologists, public TAILORING TOBACCO CONTROL EFFORTS TO THE COUNTRY 157 health workers, activists, and media advocates reflected the broad impli- cations of the issue. It became clear at the conference that the epidemic would not disappear soon or on its own: a policy response was essential. As a direct result of the conference, the TASCP developed its first edu- cational poster. At the conference, Dr. Jureerut Bornvornwattanuvongs, a pulmonary disease specialist at Chonburi provincial hospital, presented a research paper reporting smoking rates for doctors, teachers, and Bud- dhist monks-all influential opinion leaders in Thai society. The TASCP used this research information to focus on a campaign to change the reg- ular practice of offering cigarettes to monks. Posters reading "Offering cigarettes to monks is a sin" were printed and distributed, as well as "Smoke-free zone" and "Thank you for not smoking" stickers. The TASCP's approach was to remain positive-not to condemn smokers, but to oppose pushing cigarettes on others. Subsequently, in 1988, the TASCP took advantage of a clinical epidemi- ology conference in Thailand, where Dr. Richard Peto, an epidemiologist and statistician from Oxford University, was the featured speaker. Peto later proved to be a very helpful resource in Thailand's tobacco control struggle. The TASCP used the opportunity of the conference to call for action to prevent 1 million Thai children from dying from cigarette smok- ing, as had been projected by Peto (TASCP 1988). All of these efforts and early successes set the stage for Thailand's later determination to fight the U.S. trade sanctions. Challenges from Beyond: Tobacco Trade Wars In the late 1980s Thailand was suddenly awash with cigarette advertise- ments. The Thai Tobacco Monopoly (TTM) began promoting its product in response to the sudden appearance of advertisements for foreign ciga- rette brands. Until then, the TTM had seen no reason to advertise, since it was a monopoly and foreign cigarette brands were available only illegally or through airport duty-free shops in Bangkok. In the words of the U.S. Tobacco Merchants Association, the Thai state-run tobacco industry, which had come into existence to displace British American Tobacco after World War II, was "fat and extremely uncompetitive" (Tobacco Merchants Association 1988). But now the TTM faced an advertising war with for- eign producers (Frankel 1996). Meanwhile, the TASCP, concerned that the foreign companies were advertising in an effort to launch their brands in Thailand, urged the government to ban all advertising, both domestic and foreign. In January 1988 the TTM applied to the cabinet for funds to build a new, more productive, and more efficient tobacco factory. Although the project was initially approved, the decision was soon reversed because of 158 P .AKIT VATEESATOKIT media protests fueled by the TASCP General Prem-a respected career soldier who was invited to be prime rninister for eight years by the elected coalition parties, even though he had not run for election-was respon- sive to tobacco control advocates. He said at the time that it was not right for the government to obtain income from such1 an inappropriate source. He did allocate some funds for new rnachinery for the TTM's existing fac- tory, but at the same time the cabinet instructed the MOPH to draft a plan for tobacco control. In April 1988 the MOPH presented a tobacco cDntrol plan that was approved by the cabinet in its entiret. Dr. ]-[ata, Chitcnondh, deputy direc- tor general of the ministry's Department of \4edical S2rvices, was responsi- ble for drafting the comprehensive plan. One of the components was an advertising ban, which the TTM did not object to, since it knew it could never match the huge resources of the international tobacco companies. In December 1988, however, when the international tobacco companies were still advertising (claiming that the p-rohibition oy the cabinet was an executive order, not a law, and therefore did not have to be followed by the private sector), the TTM protested to the government. The cabinet directed the Consumer Protection Board, a government agency operating under the auspices of the Prime Mlinister's Office, to find a means of stop- ping cigarette advertising by law. In February 1989 the board added tobacco to the list of regulated products that could not be advertised under the 1979 Consumer Protection Act. The international companies were given one month to dismantle and remove all their billboards and advertisements. (They refused to comply for nine months.) In February 1989 the cabinet appointecl the National Committee for the Control of Tobacco Use (NCCTU, as specified in the tobacco control plan. The committee was chaired by Chuan Lcekpai, minister of public health, and included members from the TASCP and the press. Chitanondh served as secretary. It was clear then that the committee would have to formulate and coordinate a comprehensive tobacco control policy. In March 1989, when the Ministry of Finance proposed opening the market to foreign cigarettes, the author, as the TASCP's executive secre- tary, personally handed a letter to Major General Chunhawan, the new prime minister, opposing the move. The NCCTU followed up with another letter to the cabinet In response, the rrinistry withdrew the market-opening proposal, and the matter was believed to be settled. It came as a shock when, only two nonths later, it was learned that the U.S. Trade Office had accepted the U.S. CigarettE. Export Association's petition to investigate Thailand under Sectio ri 301 of the 1974 U.S. Trade Act. No one had thought that Thai and coulci be forced to open the mar- ket (Vateesatokit 1996), and the strength of the L.S. tobacco lobby had certainly been underestimated. TAILORING TOBACCO CONTROL. EFFORTS TO THE COUNTRY 159 Minister of Public Health Leekpai immediately expressed his opposi- tion to the U.S. use of the Trade Act against Thailand, and within a month international support was growing for the country's stand. In June the John Tung Foundation, an NGO in Taipei, Taiwan (China), that concen- trates on tobacco control, invited the author to represent Thailand at a meeting to discuss, plan, and lay out a strategy. The foundation feared that Thailand was just a step toward opening the whole Asian market. About two dozen people attended the conference. Among them were Ted Chen, representing the American Public Health Association, Greg Con- nolly from the Massachusetts Department of Health, Richard Daynard from Northeastern University in Boston, and Terry Pechacek from the U.S. National Cancer Institute. Others at the meeting included tobacco control advocates from Japan, the Republic of Korea, and Taiwan (China), all of which had reluctantly given in to U.S. pressure on cigarette trade under Section 301. It was hoped that Thailand would take a strong stand and avoid the same problem. At the conclusion of the meeting, the Asia- Pacific Association for the Control of Tobacco (APACT) was established. The conference resolution called for U.S. president George H. W. Bush to exclude tobacco from the Section 301 trade items and for APACT to coor- dinate tobacco control activities in the region. Thailand would be the test case (Chen and Elaimy 1994). Point-Counterpoint: Trade versus Health At the APACT meeting, Connolly strongly suggested negotiating the tobacco control issue with the U.S. Trade Office from the perspective of health rather than trade. Initially Thailand had no health representative in its delegation, and there was some resistance to the author's participation for fear of irritating the Trade Office. The author did manage to work him- self onto the delegation and, along with Dr. Surin Pitsuwan, a Harvard- educated Democrat member of Parliament, asked for a public hearing to present Thailand's case. The two also lobbied health organizations and made presentations at international conferences describing the threat to Thailand. In a short space of time in 1990 the author attended several complemen- tary events to gain support for Thailand. First was the American Cancer Society's "Trade for Life Campaign" summit in Washington, D.C., attended by world tobacco control leaders, where the GLOBALink computer network to speed tobacco control communications was launched. Next was the Sev- enth World Conference on Tobacco or Health, in Perth, Australia. There Con- nolly and the author worked on strategies for negotiations with the U.S. Trade Office and for the U.S. congressional hearings scheduled for May (Vateesatokit 1990b). Along with William Foege, who was then executive 160 PRAKIT VATEESATOKIT director of the Carter Center, they testified before the U.S. Senate Committee on Labor and Human Resources, chaired by SLn. Eclward Kennedy.' Fol- lowing that, Dr. Judith Mackay of the Asian Trobacco Consultancy, John Sef- frin of the American Cancer Society, C-arlos A,lvarez Herrera, from Argentina and chairman of the Latin American Coordinating Committee on Smoking and Health, and the author testified before the House 3ornmittee on Energy and Commerce, Subcommittee on Health zand tnie Environment, chaired by Rep. Henry Waxman. At the 15th Intemational Cancer Conference, held in August 1990 in Hamburg, Germany, vvith support frcm the American Can- cer Society, the author presented the Tha:L case in a lkst effort to build sup- port (Vateesatokit 1990a). After two inconclusive rounds of negatiations vwith the Thai govern- ment, the U.S. Trade Office referred the dispute to a General Agreement on Tariffs and Trade (GATT) panel. Severa,l roLinds of testimony before the panel were held in 1990, with the Wl-[O supporting Thailand and the European Union supporting the United States. Finally, the GATT ruled that Thailand's import ban was contrary to trade provisions but that Thai- land could maintain and introduce toba2co control measures as long as they applied to both domestic and foreign products (GATT 1990; for the details of the GATT adjudication, see Ch tanon,dh 2001). Toward the end, when the GATT decision was known but not yet announced, the U.S. Trade Office made one last unsuccessful attempt to gain victory by obtaining Thailand's signazure on an agreement that would have allowed point-of-sa]e promotion-something that is prohib- ited under Thailand's tobacco control law of 1%89. The Thai cabinet moved quickly to declare the mar; a -cessed Jan. 13, 2003. Bangkok Post. 2001. "AFP: Thai Anti-Smoking lDrive Wins Praise." Feb. 2, p. 5. Buasai, S. 1993. "The Increase of the Excise Tax." Paper satbmitted for considera- tion by the Thai cabinet, Dec. 7. Chaloupka, F. J., and A. Laixuthai. 1996 "U.S. Trade Policy and Cigarette Smok- ing in Asia." 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International Union against Cancer. . 1990b. "Tobacco and Trade Sanctions: The Next Victim after Thailand." In Tobacco aind Health 1990: The Glcbal War. Procecldings of the Sevenith Conference on Tobacco or Health, April 1990, Perth, Australia. Geneva: World Health Organization. - 1996. "Tobacco Control in Thailand." Sirira; Hospital Gazette 48 (suppi.): 119-52. 1997. "Tobacco Control in Thailand." Mahidol Jon mal 4 (2): 73-84. 2001. "Thai Tobacco Control. Development through Strategic Alliances." Developmenit Bulletin 54 (April): 63--66. Vateesatokit, P., B. Hughes, and B. Pitthphakdee. 2000. "Thailand: Winning Bat- tles, but the War's Far from Over." Tobacco Coatrol 9 (2): 122-27. Available at . Wangsuphachart, V., and others. 1995. "Cross Sectional Study of Cigarette Smok- ing among Women of Specific Occupations " Mamidol Uniiversity Research Abstracts (Thailand). World Bank. 1993. World Dcvelopnient Report 1993: Ilnvestilng in Health. New York: Oxford University Press. . 1999. Curbinig the Epidemiiic: Gowrinnen,'s aind the Economnics of Tobacco Con- trol. Development in Practice series. Washington, DI.C. Index Abedian, Iraj, 144 ASH (Action on Smoking and Health) Action on Smoking and Health (Thailand), 168; funding and, 168-169; (Thailand). See ASH name changed to from Thai Anti- ADHUNIK (Amra Dhumpan Nibaron Smoking Campaign Project, 164, 176. Kori) (Bangladesh), 13, 20, 21, 22, 23 See also TASCP; staff of, 168 Advisory Board on Tobacco Use Control Asian Tobacco Consultancy, 160 (Brazil), 42 Asia-Pacific Association for the Control AFTA (ASEAN Free Trade Agreement), of Tobacco (APACT), 159 167, 173 Association for the Prevention of Drug AFUBRA (Brazilian Tobacco Growers' Abuse (MANAS) (Madok o Nesha Association), 52, 55, 61-62 Nirodh Shansthya) (Bangladesh), 13, Ahmed, Saifuddin, 23, 26, 30 21, 25 Akiz Bidi, 16 Australia: tobacco tax in, 167; Victorian All Africa Conference on Tobacco and Health Promotion Foundation Health, 141 (VicHealth) in, 164 American Cancer Society, 28, 32, 41, 105, 159, 160 BADSA (Body Against Destructive American Heart Association, 49 Social Activities) (Bangladesh), 25 American Public Health Association, 159 Banco do Brasil, 43 Amir, Tania, 22, 23-24, 26, 30 Bangladesh: development in, indicators Amra Dhumpan Nibaron Kori of, 2, 4-5; economics of tobacco in, (ADHUNIK) (Bangladesh), 13, 20, 21, 18-20; general description of, 13; 22, 23 illiteracy in, 4, 16; life expectancy at Antidrug Council (Madok Drabya-O- birth in, 4; malnutrition resulting from Nesha Birodi Council) (MANOBIK) tobacco use in, 9, 10, 19; tobacco (Bangladesh), 26 control in. See Bangladesh tobacco Anti-Tobacco Use Week (Brazil), 41 control; tobacco industry in, 16-18; ANVISA (National Sanitary Vigilance tobacco production in, 14-15, 16; Agency) (Brazil), 47, 51, 52, 56, 57, 66 tobacco product prices in, 6; tobacco APACT (Asia-Pacific Association for the use in, 4, 9, 14-16, 19, 20-21, 36 Control of Tobacco), 159 Bangladesh Anti-Tobacco Alliance. Arcoverde, Waldir, 42 See BATA Arts sponsorship by tobacco Bangladesh Cancer Society, 13, 18, 21 industry, 167 Bangladesh Tobacco Company (BTC), 16 ASEAN Free Trade Agreement (AFTA), Bangladesh tobacco control, 6, 13-37; 167, 173 chronicle of, 20-28; competing 179 180 INDEX priorities and, 34; education of public Brazi'ian 'lMedical Academy, 54 and politicians and, 27, 32-33; funds Braziiian 'Medical Association, 41 to support, 22-23, 31-32; laws Bra2ilian Societies of Cardiology and regarding, 29; lessons learned in, Pediatrics, 54 31-36; maintaining strong alliance Brazilian TobaccD Growers' Association and, 34-35; politics and, 28-30, 32-34. (AIFUBRA), 52, 55, 61-62 role of nongovernmental Brazil tobacco control, 11, 38-70; organizations (NGOs) in, 6, 7, 20-28; beginni ngs of, 40-42; business standing up to opposition and, 35-36; participation in, 42-43; "cascade" working with media and, 32-34 system for training and, 57-59; Basisfor the ntipleniienitationi of a Tobacco importLnce of partnerships and, 54; Control Programn (Goldfarb et al.), 48 laws regarding, 6, 42, 45, 51-52, 55, BAT. See British American Tobacco 56-57; lessons learned in, 66-67; BATA (Bangladesh Anti-Tobacco N ational Toba cco Control Program Alliance), 17, 21, 31, 35; activities (NCTP) and, 42-52. See also NCTP; championed by, 27-28; efforts against pictures to accompany warnings and, BAT's Voyage of Discovery campaign 57; public support and, 53-54; and, 23-34, 26, 36; founding of, 22, 27; research projects and, 49-51; scope of funding for, 22-23, 31-32; importance Brazil's tobacco problem and, 38-40; of, 24-28; mission of, 26-27, taxation and, 66; tobacco industry organizations in network of, 25-26. opposi .ion to, 54-55 See also individiual organizations; British American Tobacco (BAT), 13, 16, relationship with government and, 19, 157; advertising by, 21-22, 23, 29; 29-30; WAAHO's 2001 Tobacco Free attempts to resist regulation and, World Award received by, 30 17-18, 55; power of, 20; rock concerts Beatty, Perrin, 83 sponscred by, 29; in South Africa, 122; Bhorer Kagoj, 29, 33 Souza Cruz as Brazilian arm of, 55, 62; Biman, smoking prohibited on flights toyage of Discovery campaign of, of, 29 21-22,23-24, 26,36 Body Against Destructive Social Brundtland, Gro Harlem, 149 Activities (BADSA) (Bangladesh), 25 BTC (Bangladesh Tobacco Company), 16 Bornvomwattanuvongs, Jureerut, 157 Buasai, Supakem, 162, 164 Botha, P. W., 123 Bush, CLorge H1. W., 159 Bouchard, Benoit, 83 Brazil: development in, indicators of, 2, CAB (Consumers' Association of 4-5; econonucs of tobacco in, 39-40; B3angladesh) 25 export earnings from tobacco in, 39-40; Callard, Cynthia, 86 government support for tobacco in, 40; Canada: development in, indicators of, illiteracy in, 4; life expectancy at birtlh 2, 4-5; life expectancy at birth in, 2-3, in, 4; tobacco control in. Scc Brazil 4; tobacco control in. See Canada tobacco control; tobacco industry in, tobacco control; tobacco industry in, 54-55; tobacco production 1n, 39-40; 77-81, 93; tobacco production in, 72, tobacco product prices in, 45-46, 62-65; 73-74, tobacco product prices in, 72, tobacco tax in, 66; tobacco use in, 4, 74, 87-90, 91; tobacco tax in, 6, 71, 38-39, 45-46, 62, 65 87-90, 94; tobacco use in, 3, 4, 71, Brazilian Cancer Society, 41 72-73, 87-90, 91, 92, 94 Brazilian Cigarettes: Analyses anid Canada tobacc o control, 9, 71-96; Proposals to Rediuce Consumenptioni (Silva advertising tug-of-war and, 77-81; et al.), 47 budget for, ti5; generation before, INDEX 181 72-74; key dates in, 95-96; laws CCSNA (Centre for Clinical Studies on regarding, 6, 57, 79, 80-92, 93, 172; Nicotine Addiction) (Brazil), 59 lessons learned in, 92-95; during the CDC (United States Centers for Disease 1980s, 74-76; pictures to accompany Control and Prevention), 41, 49, 51 warnings and, 57, 110, 150, 168, 171; Centers for Disease Control and policy initiatives and, 76-92; product Prevention (CDC) (United States), 41, labeling and, 81-84, 110, 150; research 49, 51 and, 76; smoke-free workplaces and, Centre for Clinical Studies on 84-87, 84-97; taxation and, 6, 71, Nicotine Addiction (CCSNA) 87-90, 94; working through courts (Brazil), 59 and, 90-92 Charlewood, Carole, 127, 128, 132 Canadian Cancer Society (CCS), 32, 75, Chen, Ted, 159 80, 84, 86-87, 89, 94, 95 China, tobacco use in, 162, 170 Canadian Council for Tobacco, 76 Chitanondh, Hatai, 158, 161, 167 Canadian Council on Smoking and Chowdhury, Arup Ratan, 21 Health (CCSH), 76, 77, 89 Chunhawan, Chatchai, 158, 160 Canadian International Development CIDA (Canadian International Agency (CIDA), 32 Development Agency), 32 Canadian Lung Association, 76, 81 Cigarette packs, warnings on, 2, Canadian Medical Association, 80, 89 15-16, 29, 43, 51, 56-57, 71, 73, Cancer Association of South Africa, 122, 81-84, 85,105, 109, 110, 116, 118, 124, 128 121, 122, 135, 137, 143, 146, 150, Cancer Centre and Institute (Maria 155, 161, 168, 171; pictorial, 57, Sklodowska-Curie Memorial Cancer 110, 150, 168, 171 Centre and Institute of Oncology), 118; Cinemark, 129 drafting of tobacco control legislation CLACCTA (Latin American and, 107; Kazimierz conference Coordinating Committee for Tobacco organized by, 105; studies conducted Control), 41, 49, 51 by, 97-98, 102; WHO Collaborating Coalition Against Tobacco (CAT) Centre on the Action Plan for a (Bangladesh), 21n Tobacco-Free Europe at, 106 Collins, Mary, 83 Cape Restaurateurs Association, 124-125 Collishaw, Neil, 77, 87, 162 Cape Times, 139 Commonwealth Games Council, 146 Cape Town City Council, 123-125, 135, Connolly, Greg, 105, 159-160, 170 138-140 Consenstis of tie Treatmenit of Tobacco Cardoso, Fernando Henrique, 55 Users, 45, 59 Carter, Jimmy, 160n Consumers' Association of Bangladesh Carter Center, 160 (CAB), 25 CAT (Coalition Against Tobacco) Coordinating Committee for Tobacco (Bangladesh), 21n Control in Brazil (CCCTB), 41, 44 A Catalogue of Deceptioit (NSRA), 79 Cavalcante, Tania M., 44 Data and Facts, 48 Caxton, 147 Daynard, Richard, 159 CCCTB (Coordinating Committee for Deaths, tobacco-related, ix, 1, 2, 9, 10, 39, Tobacco Control in Brazil), 41, 44 72, 74-75, 80, 82, 97, 99, 100-101, 115, CCS (Canadian Cancer Society), 32, 75, 119, 125, 146, 154, 156, 157 80, 84, 86-87, 89, 94, 95 de Kierk, F. W., 123, 128, 134 CCSH (Canadian Council on Smoking Dependence on tobacco, treatment for, and Health), 76, 77, 89 59, 109, 117 182 INDEX Developing cou ntries. See also individiual Folk Doctors Foundation (FDF) countries: tobacco-related deaths in, 1, 2; (Thailand), 1,5-156, 164 tobacco-related disease in, 1, 3; tobacco Foole, Frnersor, 77 users in, 1 Frarnew-)rk Convention Alliance, Dhaka Ahsania Mission (Bangladesh), 25 26, 28 Dingwall, David, 80, 81 F-&mework Convention on Tobacco Disease, tobacco-related, ix, 1-2, 3,4-5, Control (FC1 C), x, 10, 11, 26, 28, 30, 10, 16, 25, 39, 71, 97, 99, 100, 101, 48, 52, 56, 173; Intergovernmental 114-115, 119, 125, 126, 137, 154, 135, Negotiating Body (INB) for, 26 156. See also Deaths, tobacco-related: FLKNASA (Nat onal Health Foundation) Nicotine (,Brazil), 42, -4, 50 Du Plessis, Barend, 123 Gelball)y. Rhonda, 164 Economics of Tobacco Control in South GAkIT (General Agreement on Tariffs Africa (ETCSA) Project, 143-144 and Trade), 160-161, 167, 170, 175 Ecoin0omiic Timles, 33 GCczctte, 131-13 2, 136, 138, 139, 149 Education: in Bangladesh, 27, 32-33; in General Agreement on Tariffs and Trade Brazil, 57-61; legislative action and, (GATT), 160-161, 167, 170, 175 60-61 Ghas Pl-ul No 3i (Bangladesh), 25 Efroymson, Debra, 10, 19 Gherardt, Gerinano, 42 Egypt, household expenditures on Gil, Gilaerto, (2 tobacco products in, 10 Gicbe and Mail. 80, 89 Epp, Jake, 79 Goldfarb, Luisa M. da Costa e Silva, 44 ETCSA (Economics of Tobacco Control Great American Smoke-Out, 106 in South Africa) Project, 143-144 Great Polish Smoke-Out, 106 EU. See European Union (EU) European Union (EU): taxes on Hasina, Sheiki, l8 cigarettes in, 111; warnings on Health Buildings International, 135 cigarette packs sold in, 110 Health Canada, 80, 83, 89 Health problems, tobacco-related, ix, FCTC. See Framework Convention on 1-2, 3, 4-5, 10, 16, 25, 39, 71, 97, 99, Tobacco Control 100, '01, 11 4-115, 119, 125,126,137, FDF (Folk Doctors Foundation) 154, 155, 156. See also Deaths, tobacco- (Thailand), 155-156, 164 related; Ni otine Federal Council of Dentists (Brazil), 54 F[ealth Promotion Foundation (Poland), Federal Mviedical Councl (Brazil), i4 106-107 Federal Nutrition Council (Brazil), 54 I lealth Promotion Office (Thailand), Federation of Hotel, Liquor and 165, 166 Catering Associations of South Africa Elcaltlh Systerns Research Institute (FEDHASA), 125 (HS I), 162, 164, 168 FEDHASA (Federation of Tiotel, Liquor H leart and Stroke Foundation of Canada, and Catering Associations of Souta 76, 80-81, 83 Africa), 125 Hieart Found 3tion of Southern Africa, Feitosa, Jose do Vale, 42 124,128 Feitosa, Tereza P., 44 Herrera, Carlos Alvarez, 160 Finland, lung cancer mortality rate in, 99 Hijjar, Migucl Aiub, 42 Flis, Ed, 78 1i-lotel an1d Caterer, 140 Flue-Cured Tobacco Marketing Agency, 75 E-HSRI (Health Systems Research Foege, William, 159-160 Institute), 162, 164, 168 INDEX 183 IACIB (Institute of Allergy and Clinical Kazimierz Declaration, 105-106 Immunology, Bangladesh), 25 Kennedy, Edward, 160 IDRC (International Development Keys, Derek, 141 Research Centre), 49, 51, 143 Kliegerman, Jacob, 51 Illiteracy: in Bangladesh, 4, 16; in Kraprayoon, Suchinda, 172 Brazil, 4; in South Africa, 4, 135; in Kriel, Hernus, 135 Thailand, 4 Krzakowski, Maciej, 108 IMF (International Monetary Fund), Kyle, Ken, 75, 77 169, 171 Imperial Tobacco Ltd., 79, 93 Lachance, Victor, 77 INB (Intergovernmental Negotiating LaMarsh, Judy, 73, 96 Body) (for the Framework Convention Latin American Coordinating on Tobacco Control), 26 Committee for Tobacco Control INCA (National Cancer Institute) (CLACCTA), 41, 49, 51 (Brazil), 38, 47; Centre for Clinical Latin American Coordinating Studies on Nicotine Addiction Committee on Smoking and (CCSNA) at, 59; designation of, as Health, 160 WHO Collaborating Center, 48-49; Law and Society Trust, Bangladesh NTCP's relocation from and back to, (LSTB), 22, 23, 25, 26, 30, 32 44; Tobacco or Health Prize awarded Leeartham, Phisit, 165, 174 by WHO to, 45 Leekpai, Chuan, 158, 159, 160, 165, 174 India: BATA at regional meetings in, 28; LSTB (Law and Society Trust, household expenditures on tobacco Bangladesh), 22, 23, 25, 26, 30, 32 products in, 10; tobacco use in, 162 Institute for Global Tobacco Mackay, Judith, 160, 163, 171 Control, 169 Madok Drabya-O-Nesha Birodi Council Institute of Allergy and Clinical (MANOBIK) (Antidrug Council) Immunology, Bangladesh (IACIB), 25 (Bangladesh), 26 Intergovernmental Negotiating Body Madok o Nesha Nirodh Shansthya (INB) (for the Framework Convention (MANAS) (Association for the on Tobacco Control), 26 Prevention of Drug Abuse) International Development Research (Bangladesh), 13, 21, 25 Centre (IDRC), 49, 51, 143 Mahler, Halfdan, 156 International Monetary Fund (IMF), Mahood, Garfield, 75, 77, 171 169, 171 Malawi, export earnings from tobacco International Tobacco Growers in, 39 Association, 56 Malaysia, tobacco product advertising International Tobacco Initiative, 143 in, 147 International Union against Cancer Malnutrition, resulting from spending (UICC), 102, 105, 106 on tobacco, 9, 10, 19 Islam, Nurul, 20, 22 MANAS (Madok o Nesha Nirodh Israsena, Bajr, 170 Shansthya) (Association for the Prevention of Drug Abuse) Japan, high number of women smoking (Bangladesh), 13, 21, 25 in, 170 Mandela, Nelson, 133, 134, 140, 146, 147, Jatene, Adib, 44, 46, 47 148, 149 Johannesburg City Council, 126-127, 135 MANOBIK (Madok Drabya-O-Nesha John Paul II (pope), 107 Birodi Council) (Antidrug Council) John Tung Foundation, 159 (Bangladesh), 26 184 INDEX Manuel, Trevor, 142, 143 National Program for Family-Run Maria Sklodowska-Curie Memorial Agricultural Businesses (PRONAF) Cancer Centre and InstitLte of (Brazil), 40 Oncology. See Cancer Centre and Nat onal Sanitary Vigilance Agency Institute (ANVISA) (Erazil), 47, 51, 52, 56, 57, 66 McDonald, Lynn, 79, 86 National Schocl-Based Health Media: revenue from tobacco product Knowledge (Saber Saude) Program advertising and, 33-34, 129, 132, (Brazil), 49, 60, 62 137-138; tobacco industry closely tied NEtional Tobacco Control Program to, 129-130; working with, 32-34 l'Brazi ). See NTCP Medical Association of South Africa, 124 NCAS (National Council Against Medical Research Council (South Smoking) (Soruth Africa), 122, 124, 128, Africa), 125, 126, 127, 30, 131, 131, 141; first antismoking commercial 133-134, 135, 137, 147, 149 and, i29-13(0 Meiring, Kobus, 124 NCCTU (National Committee for the MOPH (Thai Ministry of Public Health), Control of Tabacco Use) (Thailand), 155-156, 160, 161, 162, 164, 165, -68, 158, 159, 17] 176; Tobacco Consumption Control NCTU (National Commission on Office (TCCO) of, 161, 166, 169, 174 Tobacco Use) (Brazil), 52; creation of, Moraes, Marcos, 44 52; tobacco :,rowing ban rumors dealt Muller, Peter, 124 with by, 55-56 Munroe, John, 96 Neville, Bill, 80-81 New Zcaland. Victorian Health Naripokho (Bangladesh), 14 IPromotion F7oundation (VicHealth) Nasionale Pers, 129, 137 in, 164 National Campaign for Action on Nicotine: add ction and, ix, 1, 59, 117; Tobacco (Canada), 80 nicot-ne reF lacement therapy and, National Cancer Institute (Brazil). 59, 117 See INCA N on-Smokers' Rights Association National Cancer Institute ,NSI'A) (Canada), 75, 76, 77, 78, 79, (Thailand), 155 30, 83, 84, 86-87, 88, 89, 162, 172 National Cancer Institute NSRA (Non-S,mokers' Rights (United States), 159 Associatior,) (Canada), 75, 76, 77, National Commission on Tobacco Us,e 78, 79, 80, 1 3, 84, 86-87, 88, 89, (Brazil). See NCTU 162, 172 National Committee for thc Control of NTCP qNational Tobacco Control Tobacco Use (NCCTU) 'Thailand), Program) (Brazil), 38, 42-52, 61; 158, 169, 171 actiN ities of, 44-48, 49, 50; education National Coordination of Tobacco as b.isis of, 57-60; establishment of, 42; Control and P'rimary Cancer relocation rom and back to INCA Prevention (CONTAl'P) (Brazil), 48 and, 44 National Council Against Smoking (South Africa). See NCAS IJie 0Lserver, 33 National Day Against Tobacco (Brazil), OECD (Organisation for Economic Co- 42-43, 45 operation and Development), 73 National Health Foundation (FUNASA) Onvimol, So nkiat, 156 (Brazil), 42, 44, 50 Crganisatior for Economic Co-operation National Non-Smokers' Forum and Development (OECD), 73 (Bangladesh), 13, 22, 25, founding of, 21 Ourairat, Ar:hit, 162, 163, 172, 174 INDEX 185 PAHO (Pan American Health Pratyasha (Bangladesh), 26 Organization), 49, 51 Programme for Appropriate Technology Pan American Health Organization in Health, Canada (PATH Canada), (PAHO), 49, 51 22-23, 26, 28, 31, 32 Passive smoking, 50, 140. See also PRONAF (National Program for Family- Secondhand smoke, protection from Run Agricultural Businesses) PATH Canada (Programme for (Brazil), 40 Appropriate Technology in Health, Public places, ban on smoking in, ix, 118, Canada), 22-23, 26, 28, 31, 32 126-127, 135, 138-140, 148-149 Pechacek, Terry, 159 Peto, Richard, 102, 105, 157, 161-162 Qu6bec Coalition for Tobacco Control, 81 Phillip Morris, 62, 167 Physicians for a Smoke-Free Canada, 80, RDA (Rural Doctors' Association) 86 (Thailand), 156 Pitsuwan, Surin, 159, 174 Rede de Desenvolvimento Humano Poland: development in, indicators of, 2, (REDEH) (Brazil), 54 4-5; government monopoly of tobacco REDEH (Rede de Desenvolvimento sector in, 102-103; life expectancy at Humano) (Brazil), 54 birth in, 4, 97; lung cancer mortality Rembrandt group, 142; close rate in, 97, 99, 100-101, 114-115, 119; relationship with South African tobacco control in. See Poland tobacco government and, 123-124; media control; tobacco production in, 103; company shares owned by, 129, 137; tobacco product prices in, 6, 103-104, most of South African tobacco market 111-112, 116; tobacco tax in, 7, controlled by, 122 103-104, 111-112, 116; tobacco use in, Remgro, 122 3, 4, 8, 97-103, 113-115, 116 Research for International Tobacco Poland tobacco control, 97-120; Health Control (RITC), 49, 143 Promotion Foundation establishment Richemont, 122 and, 106-107; history of high tobacco Rigatto, Mario, 41 consumption and, 97-103; impact of Rimpela, Matti, 102 democracy and free market on, RITC (Research for International 103-107, 112-115; Kazimierz Tobacco Control), 49, 143 Declaration and, 105-106; laws Ritthphakdee, Bung-On, 168 regarding, 6, 101, 107-110, 112, 118; RJR-Macdonald, 78 lessons learned in, 116-119; local Rock, Allan, 81, 84 involvement in, 118-119; new Rock concerts sponsored by tobacco information about tobacco and, industry, 29 101-102; new legislation for, 107-111; Rockefeller Foundation, 32, 168 during the 1980s, 99, 101; smoke-free Rosemberg, J., 41 workplaces and, 109-110; taxation Rothmans International, 122, 147 and, 7, 103-104, 111-112, 116; total ban Rothmans of Pall Mall Canada Limited, 73 on tobacco advertising and, 112, 118 Royal Gazette, 166 Polish Anti-Tobacco Society, 103 Rupert, Anton, 122, 124, 126, 142 Political will: creating, 32-34; increased Rupert, Johann, 142, 143, 144 support from, 51 Rural Doctors' Association (RDA) Pongpanich, Montree, 172 (Thailand), 156 Popkiss, Michael, 124, 125, 127, 138 Practical Guidelines for tle Implenentation of SABC (South African Broadcasting a Tobacco Control Program (Silva et al.), 48 Corporation), 129-130, 132, 143 186 INDEX Saber Sailde (National School-Based Sovtu African Medical Journal, 121-122, Health Knowledge) Program (Brazil), 125-126 49, 60, 62 South Africa tobacco control, 121-153; Sadat, Omar, 23-24 Cape Town debate and, 123-125, 135, Saloojee, Yussuf, 122, 127, 129, 131, 133, 138-140; evidence against tobacco 140, 141, 142, 150 and, 125-126; funds to support, 31; Schools, tobacco control education in, history of earLy days and early 59-60 struggles in, l21-128; Johannesburg Secondhand smoke, protection from, 71, Cit-y Council', actions and, 126-127, 84-87, 109-110, 148-149. See also 135; lawvs regarding, 6, 31, 136-149; Passive smoking; in public places, ix, lessons learned in, 149-150; Mandela 118, 126-127, 135, 138-140, 148-149; in government's support for, 133-134, workplace, 71, 84-87, 109-110, 127, 140-149; Parliament's debates on, 148-149 134-136; roac, to legislation and, Seffrin, John, 160 131-136; taxation and, 7, 121, 123, Seftel, Harry, 125 128, 141-143, 144-145; tobacco Serra, Jose, 51, 54, 57 industry's close ties with Seventh World Conference on Tobacco government and, 122-123, 130-131, or Health, 159-160 132-133 Shisana, Olive, 126 Southeast Asia Tobacco Control Silap-acha, Banharn, 170 Alliance, 168 Silap-acha, Kanjana, 170 Souza Cruz, 55, 62 Silva, Vera Luiza da Costa e, 42, 44, Sports sponsorship by tobacco industry, 48, 51 78, 81, 121, 1:'8, 131, 143, 147-148, 167 SINDIFUMO (Tobacco Industry Sri Lanka, cigarettes as cause of poverty Syndicate) (Brazil), 61-62 in, 10 Sixth World Conference on Tobacco or Steinthai, Suraldat, 164 Health, 156-157 Steyn, Krisela, 125, 126 Smokeless tobacco, 14, 105, 109 Suo:awongse, C'hoochai, 156 Smoking, ban on: in public places, ix, Suriyawongpa'sal, Paibul, 156, 163 118, 126-127, 135, 138-140, 148-149; in Sa eano-, David, 75, 77, 88, 162-163, 172 workplace, 71, 84-87, 109-110, 127, 148-149 TAG (Tobacco Action Group) (South Smuggling of tobacco products, 66, Africa), 128- 129, 130, 132, 135 89-90, 142, 146 Taiwan, high number of women South Africa: development in, indicators s]moking in, 170 of, 2, 4-5; household expenditures on TASCP (Thai Anti-Smoking Campaign tobacco products in, 10; illiteracy in, Project), 158, 160, 162, 167; formative 4, 135; life expectancy at birth in, years of, 156-157; founding of, 3, 4; tobacco control in. See South 155-156, 175; name changed to Action Africa tobacco control; tobacco on Srmoking and Health, 164, 176. See production in, 122-123; tobacco also ASH; Thai Women Do Not Smoke product prices in, 121, 123, 142, 150; Project and, 170, 176 tobacco tax in, 7, 121, 123, 128, Taxes on tobacco products: in Australia, 141-143, 144-145; tobacco use in, 3, 4, 167; in Brazil, 66; in Canada, 6, 71, 121, 150 87-90, 94; in Poland, 7, 103-104, South African Broadcasting Corporation 111-112, 116; in South Africa, 7, 121, (SABC), 129-130, 132, 143 123, 128, 141-143, 144-145; in South African Business Institute, 132 Thailand, 161, 162-166, 171, 173 INDEX 187 TCCO (Tobacco Consumption Control Nicotine; production of. See Tobacco Office) (Thailand), 161, 166, 169, 174 production; products made from. See Thai Anti-Smoking Campaign Project. Tobacco product(s); smokeless, 14, See TASCP 105, 109; use of. See Tobacco use Thai Anti-Tuberculosis Association, 155 Tobacco Action Group (TAG) (South Thai Health Promotion Foundation, 171 Africa), 128-129, 130, 132, 135 Thai Heart Association, 155 Tobacco Consumption Control Office Thailand: BATA at regional meetings in, (TCCO) (Thailand), 161, 166, 169, 174 28; development in, indicators of, 2, Tobacco control: in Bangladesh. See 4-5; illiteracy in, 4; life expectancy at Bangladesh tobacco control; in Brazil. birth in, 4; Ministry of Public Health. See Brazil tobacco control; in Canada. See MOPH; tobacco control in. See See Canada tobacco control; legislation Thailand tobacco control; tobacco regarding. See Tobacco control laws; in industry in, 155, 157-158, 167, 168, Poland. See Poland tobacco control; in 170. See also TTM; tobacco production South Africa. See South Africa tobacco in, 157-158; tobacco tax in, 161, control; in Thailand. See Thailand 162-166, 171, 173; tobacco use in, 3, 4, tobacco control 154, 162 Tobacco Control, 44 Thailand tobacco control, 154-178; Tobacco control laws: in Bangladesh, 29; chronological summary of efforts in, in Brazil, 6, 42, 45, 51-52, 55, 56-57; in 175-176; funds to support, 31; GATT Canada, 6, 57, 79, 80-92, 93, 172; dispute and, 160-161, 167, 170, 175; drafted by tobacco industry, 36; health promotion and, 164-166; laws education and, 60-61; enforcement of, regarding, 31, 158, 161, 165-166, 171, 8; implementation and, 8; in Poland, 6, 172-173, 174; lessons learned in, 101, 107-110, 112, 118; in South Africa, 173-175; nongovernmental sector and, 6, 31, 136-149; in Thailand, 31, 158, 7, 168-169; opposition from United 161, 165-166, 171, 172-173, 174 States tobacco companies and, 154-155, Tobacco industry. See also individutal 166-168; pictures to accompany companies: in Bangladesh, 16-18; in warnings and, 171; successes and Brazil, 54-55; in Canada, 77-81, 93; in challenges of, 171-173; TASCP (Thai Poland, 103-104, 110; in South Africa, Anti-Smoking Campaign Project) and. 122-124. See also Rembrandt group; See TASCP; taxation and, 161, 162-166, sponsorships by. See Tobacco industry 171, 173; Thai Women Do Not Smoke sponsorship(s); in Thailand, 155, Project and, 170-171, 176; tobacco trade 157-158, 167, 168, 170. See also TTM; wars and, 154-155, 157-162 tobacco control laws drafted by, 36; in Thai Medical Association, 155, 175 the United States, 154-155, 166-168; Thai Ministry of Public Health. See voluntary code on advertising and, MOPH 78-79 Thai Thoracic Association, 155 Tobacco industry sponsorship(s): of arts, Thai Tobacco Monopoly. See TTM 167; of rock concerts, 29; of sports, 78, Thai Women Do Not Smoke Project, 81, 121, 128, 131, 143, 147-148, 167 170-171, 176 Tobacco Industry Syndicate Times Media Limited, 137 (SINDIFUMO) (Brazil), 61-62 Tinsulanonda, Prem, 158, 167 Tobacco Institute of South Africa (TISA), TISA (Tobacco Institute of South Africa), 132-133, 135, 137, 138 132-133, 135, 137, 138 Tobacco Merchants Association (United Tobacco. See also other entries beginning States), 157 with Tobacco: nicotine and. See Tobacco News, 48 188 INDEX Tobacco product(s): advertising of. See in India, 162; in Poland, 3, 4, 8, 97-103, Tobacco product advertising; 113-115, 116; in South Africa, 3, 4, 121, dependence on, treatment for, 59, 109, 153; in Tlhailand, 3, 4, 154, 162 117; price of. See Tobacco product Tobacco Use: A Pt,blic Health Issue prices; smuggling of, 66, 89-90, 142, (Rosemberg), 41 146; spending on, malnutrition Treatrment for dependence on tobacco, resulting from, 9, 10, 19; tax on. See 59, 109, 117 Taxes on tobacco products; warnings Tshabalala-MsirrLang, Manto, 149 on. See Tobacco product warnings TTM (Thai Tobacco Monopoly), 155, Tobacco product advertising, 2; in I E7-158, 161, - 67, 168, 170; Bangladesh, 16-17, 20, 21-22, 29; ban Intemational M4onetary Fund (IMF) on, ix, 9, 11, 112, 118, 121, 158; in obligation anc, 169, 171; privatization Brazil, 45-46, 54-55, 61-62; in Canada, plans and, 169', 171, 176 73, 77-81; in Malaysia, 147; media revenue from, 33-34, 129, 132, 137-138; UICC (Intemational Union against in Poland, 104, 109, 110, 112, 113, 118; Cancer), 102, 105, 106 in South Africa, 121, 122, 129, 135, 136, UNICEF, 19 137, 147; in Thailand, 157, 158; tobaccD United Kingdori, lung cancer mortality companies' voluntary code Dn, 78-79, rate in, 99, 100-101, 115 warnings in, 17, 109, 135 United States: lmng cancer mortality rate Tobacco production: in Bangladesh, in, 99, 100-101, 115; tobacco industry 14-15, 16; in Brazil, 39-40; in Canada, in, 154-155, 156-168; tobacco trade 72, 73-74; environmental effects of, 10, wars with Thailand and, 154-155, 39; native forests lost through, 39; in 157-162 Poland, 103; in South Africa, 122-123; United States Centers for Disease Control in Thailand, 157-158 and Prevention (CDC), 41, 49, 51 Tobacco product prices, ix, 2, 5, 6; in Un ted States Cigarette Export Bangladesh, 6; in Brazil, 45-46, 62-65; Association, 158 in Canada, 72, 74, 87-90, 91; in United States Trade Office, 158, 159, 160, Poland, 6, 103-104, 116; in South 161, 162, 169, 170 Africa, 121, 123, 142, 150 Tobacco product warnings: in van Walbeek, C orne, 121, 142, 149-150 advertising, 17, 109, 135; on cigarette Vateesatokit, Prakit, 156, 158, 159-160, packs, 2, 15-16, 29, 43, 51, 56-57, 71, 161, 162, 164, 165, 168, 172 73, 81-84, 85, 105, 109, 110, 116, 118, Vejjajiva, Athasit, 156, 165, 166, 172, 174 121, 122, 135, 137, 143, 146, 150, 155, Venter, Rina, 127, 128-129, 130-132, 161, 168, 171; pictures required to 133, 135 accompany, 57, 110, 150, 168, 171 Victorian Heall!h Promotion Foundation Tobacco use: in Bangladesh, 4, 14-16, 19, (VicHealth), 164 20-21, 36; in Brazil, 4, 38-39, 45-46, 62, 65; in Canada, 3, 4, 71, 72-73, 87-90, WACC (Welfare Association for Cancer 91, 92, 94; in China, 162; deaths Care) (Bangladesh), 26, 32 related to, ix, 1, 2, 9, 10, 39, 72, 74-75, Wal]esa, Lech, 104, 105 80, 82, 97, 99, 100-101, 115, 119, 125, Wangsuphachart, Varanut, 170 146, 154, 156, 157; disease related to, Wasi, Pravase, 155-156 ix, 1-2, 3, 4-5, 10, 16, 25, 39, 71, 97, 99, Waxman, Henry, 160 100, 101, 114-115, 119, 125, 126, 137, WBB (Work for a Better Bangladesh), 22, 154, 155, 156. See also Deaths, tobacco- 23, 26, 30; fL nding for, 31, 32; related; Nicotine; fires caused by, 10; workshops held by, 28 INDEX 189 Welfare Association for Cancer Care Wood, Michael, 102, 105 (WACC) (Bangladesh), 26, 32 Work for a Better Bangladesh. See WBB WHO (World Health Organization), 1, Workplace, protection from secondhand 14, 28, 32, 51, 97, 102, 105, 106, 117, smoke in, 71, 84-87, 109-110, 127, 156, 168; Collaborating Centre on the 148-149 Action Plan for a Tobacco-Free Europe World Bank, 15, 18, 111, 116, 163-164 and, 106; Commission of, on World Conference on Tobacco or Health: Macroeconomics and Health, 11; Sixth, 156-157; Seventh, 159-160 Flame for Freedom from Tobacco World Health Organization. See WHO campaign of, 30; INCA becomes a World No Tobacco Day, 13, 20, 25, 43, 45, Collaborating Center of, 48-49; 57, 102, 126, 128, 133 International Conference on Tobacco or Health of, 170; Nelson Mandela Yach, Derek, 122-123, 125-126, 130, awarded no-smoking medal by, 146; 133-134, 147, 149 1980 designated as Year of the No Young Power in Social Action (YPSA) Smoking Campaign by, 155; standards (Bangladesh), 26 for good tobacco control legislation YPSA (Young Power in Social Action) and, 107, 109; Tobacco Free Initiative (Bangladesh), 26 of, 48; Tobacco Free World Award of, 30, 149; Tobacco or Health Prize of, 45; Zimbabwe, export earnings from VicHealth model recommended by, tobacco in, 39 164; World No Tobacco Day and, 43 Zuma, Nkosazana, 126, 134, 136, Wilson, Michael, 88 140-141, 142, 143, 144, 146-148, 149 Wongsriwong, Laddawan, 156 Tobacco Control Policy: Strategies, Successes, and Setbacks tells the stories of recent struggles, successes, and setbacks in six countries-Bangladesh, Brazil, Canada, Poland, South Africa, and Thailand-in which fervent and determined effort helped strengthen policies to reduce tobacco use. This collection of experiences in diverse economic, social, and political situations demonstrates the varied and important roles played by activists, health practitioners, policymakers, researchers, NGOs, politicians, and the press. Tobacco Control Policy Strategies, Succes'ses, and Setbacks Health has a strong impact on people's social and economic well-being, in developing and developed countries. Tobacco use causes diseases and premature death, and threatens both social and economic development. This book will help countries that are struggling with the tobacco epidemic to rethink their strategies, and to do more to protect the health of their citizens. Maureen O'Neil President, Intematio'.al Development Research Centre (IDRC), Canada This is inspiring reading for policymakers seeking to implement the provisions of the Framework Convention on Tobacco Control in their countries. The six country case studies show how important it-is to have good science placed in the right hands at the right time. Tobacco control can be achieved when scientists communicate with policymakers, when policymakers act on science, and when the media and NGOs are effective. It doesn't matter if a country is a major tobacco producer ora consumer, from the North or the South, or from the developing or developed world. I look forward to the day when all WHO Member States will have positive case studies of success to report. Dr. Gro Harlem Brundtland Director General of ItI brdd Healthi Organization These accounts of how six countries put public health before corporate profits and developed strong anti-tobacco policies are a fascinating complement to the rigorous analytic work on the economics of tobacco control policies previously published by the World Bank, Wvorld Health Organization, and others. There is clear evidence that strong tobacco control policies can reduce tobacco use, and could reverse the alarming increase in deaths caused by tobacco use in many low- and middle-income countries. James D. Wolfensohn President of the lforldBank -1 * ri tc IC r mct - research for international tobacca controt THE WORLDBANK recherche pour ta lutte mondiate contre te tabac l 15402 9 117808211I354025 13 ISBN 0-82-13-,5402-7