Key Issues

A plenary address to the 10th World Conference on Smoking or Health by Garfield Mahood

I. BACKGROUND

Thank you. Chairpersons, fellow speakers, distinguished delegates, ladies and gentlemen

(Slide 1). Thank you for the invitation to address this plenary session and the honour that this bestows. I have been asked to address the conference on legislation as a key component of a comprehensive tobacco control programme.

By way of introduction, I wish to give you some background about the organizations which I represent. I am the director of two non-profit health organizations in Canada founded in 1974, the Non-Smokers’ Rights Association (NSRA) and the Smoking and Health Action Foundation. Our total budget for both organizations is about US$600,000. We have eight full-time staff working on tobacco control. Four are speakers here at the Conference.

Our organizations have played a major role in most of the significant tobacco control battles in Canada post 1975. My talk today will focus largely on the work of the Non-Smokers’ Rights Association supported by the research of our Foundation. Our Association is known for its aggressive campaign directed at achieving law reform and for its attempt to encourage denormalization of the tobacco industry. This includes, of course, accountability for the industry’s criminal and civil misbehaviour.

II. A FAILED CAMPAIGN

While it is important that this Conference projects a mood of confidence and optimism, we must look realistically at our past efforts to address the tobacco epidemic. It is difficult to determine where we are going if we have little understanding about where we have been. Frankly, I think critics could develop a good case that the international tobacco control community, this speaker included, have been ineffective, perhaps even incompetent (Slide 2).

The tobacco epidemic is a growing rather than a shrinking problem. From 1967 to 1996, world tobacco production doubled from 2.8 to more than six trillion cigarettes. The global health response has been too little, too timid, too late.

Worse, we allowed tobacco consumption to expand rapidly at precisely the time that the scientific evidence about the risks of tobacco was building dramatically.

In Perth, Australia at the 7th World Conference, I was among the panel of plenary speakers when Richard Peto and Alan Lopez released the ominous World Health Organization prediction that the international tobacco industry will kill 500 million people from among the world’s population. Five hundred million victims! The magnitude of the predicted mortality is chilling (Slide 3).

Five hundred million deaths are equal to eight times the highest estimate for deaths, both military and civilian, during the entire Second World War. Our response to such an ominous threat has been too little, too timid, too late.

III. SOME REASONS WE HAVE FAILED

Let me offer a few reasons why I think we have not been successful. First, with but a few exceptions, we have failed to focus on the vector for tobacco diseases, the tobacco manufacturers (Slide 4). Allowing the tobacco manufacturers to promote tobacco use now, given the evidence, is like allowing the promotion and sale of rats at the height of the bubonic plague, had officials of the time known the source of the plague.

Comparison of the tobacco epidemic with the bubonic plague is perhaps appropriate given the role that rats have played in both epidemics.

Second, we have failed to shift public opinion sufficiently with respect to the industry’s “legal product” argument. The industry contends that tobacco is a legal and, hence, legitimate product. Tobacco is not a legal product for children. Yet tobacco marketing targets children.

Tobacco is only legal for adults and legally on the market because society did not know the risks when the product first came on the market. To now argue that the tobacco epidemic cannot be addressed because the product is legal is to argue, absurdly, that society will never be allowed to correct its mistake. Yet the public, the media and legislators still accept the “legal product” evasion.

Third, we have failed to denormalize tobacco products and the tobacco industry. With the exception of the tobacco control media campaigns being run by the California and Massachusetts state departments of health, we have failed to strip respectability from tobacco products and to separate the tobacco industry from legitimate business.

Fourth, for too long, we have used a “blame-the-victim” approach to tobacco control. Health agencies and government health departments have focused their campaigns on individual behaviour and personal responsibility: it’s the child’s responsibility not to smoke and the adults’ responsibility to break his or her addiction. Too often, in times of competing priorities, we have placed disproportionate attention on “stop smoking” campaigns targeting individuals rather than on corporate behaviour and defective products affecting entire populations. This is not an issue of principle, of failing to show respect for individual life. It is a matter of practicality. Changing individual behaviour, one at a time, is a slow and costly process. Focusing on changing group behaviour has the potential of protecting the lives of entire populations.

Fifth, until recently in the United States, we have failed to hold the manufacturers responsible for their criminal and civil misbehaviour and for products that kill one out of two of their long term users.

Sixth, the tobacco epidemic is now recognized as a political rather than a medical problem. We have failed because, for the most part, human and financial resources have not shifted from curative approaches to the prevention of disease. We have not, as one British minister put it, changed emphasis from addressing tobacco diseases at the surgical table to prevention by decisions at the cabinet table.

Signs of greater activism include California health agencies and Australian consumer unions suing governments, the tobacco industry and its friends. Another example is the Canadian Cancer Society intervening in the courts to defend Canada’s tobacco legislation.

Seventh, huge financial incentives remain for the tobacco industry to make people ill. We have failed to persuade governments to remove these incentives and to provide serious financial and legal disincentives for manufacturers who would undermine health policy or ignore the law. Our failures are especially glaring in developed countries where we could have had the human and financial resources to fight the industry, had we altered our priorities.

The challenge then is this: will developed countries finally start to introduce the serious measures needed to eliminate the ability of the tobacco industry to market its products? Will less developed countries make the same mistakes as Canada, the United States and Europe where major changes have taken 30 years? Will it take 30 years for less developed countries with expanding tobacco markets to recognize these mistakes and take the necessary steps to protect their populations?

There is room for hope. It took Canada and Australia three decades to obtain better tobacco package warnings. Yet it only took Singapore, Thailand and South Africa one or two years to catch up. And Poland seems ready to set the warnings standard in Eastern Europe. There are many other examples of accelerated change.

IV. COMPREHENSIVE LEGISLATION IS NEEDED TO ADDRESS THE TOBACCO EPIDEMIC

Despite acceleration of change of this kind, the mortality predicted by Peto and Lopez will take place unless health interests force governments to act. Legislation is the key to the implementation of a comprehensive tobacco control plan. Fortunately, compared to other interventions, legislation can be inexpensive.

To be effective, legislation must provide governments with sweeping regulatory control over all aspects of manufacturing, importing, marketing and product use. Nothing less will do.

An example of an attempt to secure comprehensive legislation is Canada’s Tobacco Act, passed in April of this year. This legislation gives our government many of the necessary broad powers mentioned above which are needed to regulate the tobacco industry. Canada is now a large step closer to a comprehensive tobacco control plan. The question will now be “will Canada have the courage to use those powers to protect its citizens?”

Model comprehensive tobacco control plans might include these five elements (Slide 5):

1. Prevention of industry access to children

First, any plan must block tobacco industry access to children. This will not be easy. It will be easier if we pay attention to reducing both demand  and supply. Reducing demand and supply means reducing adolescent desire for tobacco while simultaneously making it more difficult to purchase tobacco. So far, legislators have not paid very serious attention to reducing either (Slide 6).

Let us look at these elements in detail. With respect to reducing supply and increasing barriers to access, we must

• raise the price
• raise the age of purchase
• decrease the sales outlets
• ban vending machines
• ban small packages (we call them kiddie packs and toddler packs)
• ban smokeless or spitting tobacco (who will seriously defend “spitting” tobacco?)
• license retailers or manufacturers, or both

Through licensing, we could hold retailers and manufacturers responsible if tobacco ends up in the hands of minors. Those who sell to kids will have a real incentive to obey the law if the penalty is the loss of a licence to sell or, for manufacturers, the de-listing of tobacco brands. Or jail.

At the same time, we must reduce youth demand. (Slide 7)

• We have to denormalize tobacco products, show why they are not like other products in the marketplace.
• We must transfer normal youth rebellion against authority from parents and teachers to the tobacco manufacturers. We must use social marketing campaigns to show adolescents how they are exploited by the industry. Focus health marketing on an industry which “rips kids off,” on the social unacceptability of cigarettes, and on health messages about bad breath, wrinkles, and impotence. Kids do not like to be “ripped off.” The California and Massachusetts state health campaigns have been breaking new ground in this critical area (Slide 8). These slides illustrate California’s attempt to isolate and denormalize the industry. (Slide 9) The campaign theme “The tobacco industry is not your friend” is a classic.

2. Informed Consent

a. Improving information

(Slide 10) The legal concept of informed consent between the buyer and manufacturer of a product is based on the consumer being fully informed about the nature of risks related to a product and the magnitude of those risks. This means that the tobacco manufacturer must tell the consumer that cigarettes not only cause lung cancer but, once lung cancer occurs, nearly 90 percent of those who contract the disease, die, within one or two years.

A state of informed consent means that young starters join the tobacco market with their eyes as wide open as possible. It means existing users have sufficient information to encourage motivation to leave the tobacco market, that smokers have as much “freedom of choice” as possible to quit smoking given the constraints that flow from using an addictive product. (Because risks are not taken as seriously by youth, implementation of the entire comprehensive plan discussed here is needed to create an environment in which children will not wish to risk tobacco addiction.)

To encourage informed consent, it is necessary both to give better information to the public and to stop tobacco industry disinformation. Providing better information

• means better warnings on packages. Major gains have been made in Canada (Slide 11), Australia (Slide 12), Singapore (Slide 13), Thailand (Slide 14), and South Africa (Slide 15).

Better information may be achieved by (Slide 16).

• introducing package inserts in order to expand package-based public education campaigns. (1)

Better information demands

• full disclosure of all toxins and all additives in cigarettes.  (2) The State of Massachusetts passed legislation in 1996 forcing disclosure of additives. Regulations implementing that law passed this month. The American tobacco industry is very unhappy with this critical U.S. precedent.

We must

• improve warnings on existing advertising. Poland is breaking critical new ground in Eastern Europe with warnings on advertising (Slide 17). And more effective package warnings in Poland are on the verge of enactment.

We must

• create effective mass media campaigns. The states of Massachusetts and California are leading the way in this regard.

The information now available via the leak of the Brown & Williamson documents has revolutionized tobacco control in the United States. We must obtain more information of this kind in other countries. We should

• press for public inquiries into the tobacco industry and for disclosure of documents. This means legislative inquiries, criminal investigations, and royal commissions.

b. Removing disinformation

(Slide 18) Disinformation must also be taken out of tobacco marketing. Both tobacco brand advertising and tobacco sponsorship advertising must be banned (Slide 19).

As this Player’s ad suggests, sponsorship advertising is often more effective than traditional brand advertising, especially when it ties live models and celebrities to the product (Slide 20).

Beautiful packages (Slide 21) imply that the product inside is safe and is associated with desirable lifestyles. Therefore we need legislation to (Slide 22).

• implement plain packaging. Plain packages are packages of uniform colour, stripped of corporate design and graphics. Plain packs would carry the brand name in standardized typeface, warnings, disclosure of toxic constituents, and other packaging information required by law. *

Legislation must enable us to

• prohibit false labelling such as “light,” “mild,” and “super light.” These labels imply falsely a tobacco product of lower risk. (3)

3. Legislation to protect non-smokers:

(Slide 23) We need legislation to protect non-smokers from tobacco-caused harm. Protection from second-hand smoke is needed for

• children in the home
• adults in the workplace and for
• everyone in public areas.

The United States is breaking new ground on environmental tobacco smoke research and policy. Canada’s Non-smokers’ Health Act passed in 1988 to take tobacco smoke out of federally regulated workplaces, was also precedent-setting. A few days ago, President Clinton announced a similar initiative. (4)

The technology exists to manufacture fire-safe cigarettes. This reform alone could save thousands of lives each year.

4. Product modification

(Slide 24) Legislation should allow governments to control all aspects of manufacturing including control of additives and allowable levels of toxins. With respect to young starters, for years, the tobacco industry has been modifying cigarettes to make it easier for children to start smoking. Through product modification, we can reverse this process.

Cigarettes are dirty drug delivery devices. For those already addicted and who cannot quit, we must improve the technology to deliver nicotine to the smoker without the poisons which are present when nicotine is delivered by cigarettes.

Legislation must give regulators the power to ban categories of tobacco products in order to push consumption toward less hazardous nicotine delivery products.

At the present time, the tobacco industry has a virtual monopoly on nicotine maintenance. Cigarette nicotine delivery systems are the most harmful but are the least regulated. Nicotine replacement products, while less harmful and with great potential to massively reduce tobacco-caused death and disease, are the most regulated.

We must create a regulatory environment in which the manufacturers of less harmful nicotine delivery systems can break the monopoly of the tobacco manufacturers so that less harmful options are available to currently addicted smokers. Obviously, this must be done with sufficient regulation and care to ensure a net gain for public health.

5. Support for smokers

Finally, (Slide 25) any comprehensive approach to tobacco control will include measures to help smokers:

• break their addiction and
• to obtain compensation from the industry for the criminal and civil misbehaviour which has caused them harm.

V. PRESSING FOR HEALTH REFORM

Legislation is critical because it is a powerful social change agent. Peer group pressure is another important agent of change. Legislation designed to reduce environmental tobacco smoke is doubly valuable because it protects non-smokers and, simultaneously, it makes the use of tobacco products socially unacceptable. This activates peer group pressure.

Litigation can be another major agent of health reform. In view of the social change that will flow from the settlement talks in the U.S.A., litigation has to be given greater attention as a social change agent.

Care when focusing on litigation is necessary. There can be little doubt that the settlement talks have changed the horizon for tobacco control in the United States. However, it is also worth noting that many if not most of the proposed settlement gains have been achieved elsewhere by way of legislation, without trading away immunity or the potential for future tobacco reform.

Nevertheless, litigation has a huge potential to affect change and severely damage the tobacco industry’s way of doing business. As a social change agent, public education is seldom very effective by itself. But public education campaigns, when combined with legislation, can be very effective.

VI. PRINCIPLES OF EFFECTIVE CAMPAIGNING

In Canada, governments have had to be dragged kicking and screaming to tobacco reform. Significant tobacco legislation has almost always followed a major battle.

With this experience in mind, I have prepared several rules of campaigning which have worked for us for 20 years. I have a few words of caution. Many of the campaign approaches that I will discuss here involve embarrassing and pressuring governments. But the pressure has to be balanced with an ability to work cooperatively and in partnership with governments.

The skill is to strike the right balance between pressure and partnership. The question becomes “how does one apply sufficient pressure to ensure that the campaign concludes with a victory for public health and not for tobacco lobbyists?”

In Canada, we have worked closely with a number of health ministers. In most cases, we applied our pressure to the government as a whole to enable the Minister of Health to overcome resistance among cabinet colleagues to the reforms which the Minister and the health community wanted.

(Slide 26) By the way, the Canadian experience is discussed in Rob Cunningham’s book, Smoke & Mirrors, on sale here at the conference.

A second caution, I do not assume that every principle for campaigning that I am going to talk about will work in all countries represented here today. Or that the campaign strategies we used will be right for all cultures. I hope that you will look on the principles that follow as ideas and as a possible campaign checklist. You will wish to modify them to fit your countries, and your budgets.

Principle 1 (Slide 27) Everyone here knows the importance of good research. But we must also do the right research to win. Economic, legal and policy research must be completed and ready to be provided to governments and the media. Where health agencies have been slow in the past is in the development of staff who can speak the language of the business press. Being able to respond to the business press will cause the press to call you first and enable you to shape the development of the media story and the issue.

Principle 2 (Slide 28) Emphasize cost-effective legislation and other public policy initiatives that have the potential to keep thousands of children out of the market. Reduce emphasis on costly labour- intensive initiatives designed to persuade individuals to break their addiction to tobacco.

The industry knows that it can bring kids onto the market faster than well-intentioned health interests can persuade addicted smokers to stop smoking. Resist programs that make the health community bail the boat while the industry drills holes in the bottom.

Principle 3 (Slide 29) Transfer responsibility for the epidemic from individual behaviour to the behaviour of the industry. This will isolate and denormalize the industry, undermine the industry’s legitimacy, and build support for legislation.

(Slide 30) This is an ad produced by the Massachusetts campaign. It exposes industry dishonesty through the confession of a former tobacco lobbyist. It also increases public support for severe measures to regulate the industry.

The ad reads,

“The tobacco industry will do almost anything to sell more cigarettes. Victor Crawford knows this first hand. While a lobbyist for the tobacco industry, he would lie to important politicians if it meant keeping the tobacco industry prosperous. Now he’s using his influence to tell the truth.”

Principle 4 (Slide 31) Build coalitions. Our campaigns have almost always been the result of team efforts. To be effective, agencies must set up procedures to cut red tape and to promote fast decision-making.

Here is one project that helped force the Canadian government to produce its long-delayed tobacco legislation (Slide 32), a two-page centrefold ad in our national English language newspaper. Utilizing a unique funding strategy, close to 150 major organizations funded one of the hardest-hitting advocacy projects in the history of tobacco campaigns.

The message on the left page holds the Prime Minister responsible for his share in 3 million future tobacco deaths. The right page contains the endorsing agencies and medical societies. Each organization paid for the space to print its name on the right page and an equivalent amount of space for the message on the left page. As we filled up the endorsing page with names, we paid for the message page on the left.

The Prime Minister is reported to have been furious about this ad. This was expected. We finally got both his attention and the legislation.

The ad was funded in about two weeks. The entire project took about one month. When pressed, we have published hard-hitting ads like this one in our national paper in less than 72 hours, from project conception to publication, including a full list of endorsers.

Principle 5 (Slide 33) Remember governments in democracies are like footballs. They move up and down the field depending upon (a) how much force is applied to them and (b) how hard one kicks them. They seldom move, especially on tobacco, without real pressure. The “3 million deaths” newspaper ad just shown is an example of a good kick to get attention.

Principle 6 (Slide 34) Don’t take “no” for an answer. Remember “no” is frequently an early stage of “yes.” The campaign for Canada’s package warning system is one of many illustrations of this rule

(Slide 35). At one point in the NSRA’s campaign for the warnings, the government sent us a message, that the warnings were “dead,” and that continued campaigning would only make the government angry. The message was blunt. Stop the campaign.

We sent back a message equally blunt. We said, “the warnings will go ahead. It was a political decision to send us that message and it will be a political decision that will cause the warnings to proceed.” It took four years and a tough campaign. But we did reverse that decision and the stark Canadian warnings did pass.(5)

Principle 7 (Slide 36) Campaign as if you are at war. Tobacco mortality rates approach those one might expect in war. And the industry has the children of the world under attack. Be as aggressive, as tough and as tenacious as tobacco death rates suggest are necessary.(6) Take risks, for our children.

In Canada, armed forces surgeon Dr. Mark Taylor discovered extremely high smoking rates in the military, in large part due to cheap cigarettes being sold to servicemen. When the military would not correct the problem and wanted to suppress the story, he risked a court martial and took the information to the media. He was as aggressive and “hard-nosed” as the health risks to the young servicemen dictated that he should be. His leadership embarrassed the military.

He put himself and his career in severe jeopardy to prevent tobacco deaths in the military. His action took integrity and courage. And his superiors did try to make him pay a price. But his actions forced the Canadian military to change its policies on tobacco.

Principle 8 (Slide 37) A corollary to the principle “Campaign as if you are at war” is “Bring intensity to your campaign.” Michael Pertschuk, former United States Federal Trade Commission Chairman and an articulate health spokesperson with the Washington-based Advocacy Institute says, “the health lobby is large enough” but it lacks “intensity.” We must bring greater intensity to our campaigns across the entire health community and we must learn to sustain the intensity until campaign objectives are achieved.

Principle 9 (Slide 38) Remove blocks to legislation. Neutralization is a critical component of social change. When individuals or groups are blocking tobacco reform, they are blocking attempts to reduce preventable deaths. You do not have to feel uncomfortable or impolite as you deal with these blocks. Make your opponents feel uncomfortable. Make legislators want to establish distance from those who support the industry.

While Canada’s new tobacco law was working its way through Parliament, some government Members of Parliament were campaigning publicly against their own tobacco legislation. (Slide 39) The NSRA published a hard-hitting ad which exposed the Ministers and Members of Parliament who were undermining the proposed law. And it embarrassed the government. The ad was “a direct hit” in the words of one insider. The Prime Minister stepped in and the opposition within the government was silenced.

Principle 10 (Slide 40) Borrow good ideas from the tobacco industry’s campaign manual. For example, the tobacco industry sets up organizations to achieve specific goals. We can too. While the tobacco industry organized artists to oppose the sponsorship provisions in Canada’s new Tobacco Act, the NSRA organized Artists for Tobacco Free Sponsorship and held news conferences to support the legislation.

(Slide 41) Here is an example from an earlier NSRA campaign, Relatives of Dead and Dying Smokers (RODDS). The tobacco industry likes to talk about harm to tobacco industry jobs from tobacco- related law reform. We decided to provide another perspective by organizing a group of our own to focus attention on the industry’s civil and criminal misbehaviour. We put a spotlight on the industry’s harm to the 45,000 fatalities from tobacco-caused disease each year in Canada and the harm done to their families.

(Slide 42) News conferences were held and charges of criminal behaviour were made. Headlines in newspapers (e.g. “Jail tobacco bosses”) undermined the manufacturers at a critical point in the tobacco campaign.

Principle 11 (Slide 43) Think strategically. Learn how to present your demands in a way that will mesh with government philosophy and public opinion. When Dr. David Kessler was Commissioner of the United States Food and Drug Administration, he displayed brilliant strategic thinking. He marketed the use of tobacco as a “pediatric disease.” He knew that if he focused his reforms on helping to keep children off the tobacco market, the industry could not win support from the public. Of course, he was right.

Principle 12 (Slide 44) Believe the “Impossible.” Then make the Impossible happen. Despite the unacceptable speed of reform in the past, we are now in a period of accelerated change in tobacco policy. We have the research. Public opinion is beginning to come onside. Everywhere we look, we see potential for major break-throughs.

I am reminded of Alice’s conversation with the Queen in the children’s story Through the Looking Glass, when the Queen urges Alice to believe “impossible things.” “One can’t believe impossible things” protests Alice.

But the Queen asks why not. “Why, sometimes I’ve believed six impossible things before breakfast,” insists the Queen.

I’m with the Queen when it comes to tobacco control. Stretch your imagination. Think of the reforms once thought to be impossible. Then work out a campaign plan to secure your goals. Don’t take “no” for an answer. Like Dr. Kessler, make the impossible happen.

September 23, 1997

Notes

(1) Package insert warnings have the potential to be an extremely effective public education tool. In Canada, 2 billion tobacco packages are sold each year. An insert system would place 2 billion perfectly targeted messages (to smokers, contemplators and the families of smokers) into the Canadian market annually. Because of the number of inserts involved, the messages could b