This week, we hear from Dr Genevieve Bois, MD and spokesperson for the Québec Coalition for Tobacco Control on the important but unfinished battle that is plain packaging of tobacco products.
Tobacco use is the number one cause of preventable deaths in Canada today, and in the UK, and in the United States – in fact in most countries around the world. Even in low-income countries that still face significant burdens from maternal health issues and infectious diseases, non-communicable diseases are on the rise, with tobacco-use leading the way as an ever-present first risk factor.
We should probably say that tobacco use remains the number one cause of preventable death, and this nuance is important because although the tremendous progress done in certain countries in terms of tobacco control should be applauded, and despite all of it, we still have long way to go. Tobacco remains the number one cause of preventable mortality.
Despite the fact that we may all seem to know that tobacco is dangerous and cigarettes kill, the sheer scale of numbers reminds us that this is not just another vague health issue: tobacco use claimed one hundred million people worldwide in the past century and might very well it will kill one billion people in the 21st century if we don’t seriously alter the current trend. This is a completely man-made and avoidable epidemic. The WHO Framework Convention on Tobacco Control (WHO FCTC) will soon celebrate its 10th anniversary and has catalyzed impressive growth in tobacco control across the world, but what remains to be done dwarfs the progress made.
In 2015, the global population covered by at least one effective tobacco control measure (of the 5 main measures identified by the WHO under the acronym POWER) has more than doubled , reaching approximately 2.3 billion people . This means roughly a third of the world is covered by… one of the main measures necessary. Even if this is great progress, most of the world’s population is still not fully protected against tobacco advertising and second-hand smoke (only 10% of the world’s population lives in a nation where an advertising ban was enacted and 16% live somewhere where smoke-free environments have been mandated, 2 of the 5 “POWER” measures). Worst of all, most children and adolescents across the world are still exposed to both advertising and second-hand smoke. That we continue to allow businesses driven by fiscal indicators only, to expose young people to marketing for products we know kill, from an industry that uses billions to hook people on one of the most addictive substance known to man, delivered in a product that will cause death in half its users, should be a source of great shame. If we look at the front runners in tobacco control, the countries where we have seen dramatic declines in smoking rates, those are countries that enforced a series of measures to restrict tobacco use: full advertising bans, smoke-free workplaces, cessation programs, health warnings, health campaigns… not just one, but all.
In 2001, Canada was the first country in the world to introduce graphic health warnings on tobacco packaging, a battle that was hard won and that several politicians and public health advocates had to push hard and long for. The tobacco industry promptly took our federal government to court, and although they lost – as they generally do – this reminded us of the tremendous power of the industry. It is an expensive and exhausting battle for a nation, one that not all politicians are able to undertake. When threats of litigations are made, many countries cannot afford to be tied up in legal challenges and back down on crucial measures. Canada and some of its provinces have been taken to court repeatedly by the tobacco industry, virtually on all effective tobacco control measures. This might have slowed down our progress even if it didn’t halt it, but not all countries are able to withstand that type of pressure. Uruguay is currently being sued by Philip Morris International for an amount of money that dwarfs its GDP. Multiple countries are also being lobbied against moving forward on measures they desperately need, in order to curb health consequences and costs of tobacco use.
One of the latest legal challenges comes for Australia, who had the courage to move forward on what is probably the most important tobacco control measure today: plain packaging. Like in Canada with the introduction of graphic health warnings, it is easy to celebrate the victory after the fact, but it doesn’t show the world the long and hard battle it took to get there. One of the reasons the tobacco industry will fight so hard against such measures is that they tend to snowball: since 2001, when Canada introduced the first graphic health warnings, 77 jurisdictions across the world have followed suit, from India to Nepal and Turkey to Mexico.
If plain packaging snowballs in a similar fashion – and we should all make sure it does – then it could spell the beginning of the end of the tobacco industry.
For those of us who don’t smoke and live in countries where tobacco packs are now hidden in shops (another crucial measure, as large displays of packages are nothing short of blatant advertising), it is hard to know how pretty, glitzy, modern and attractive tobacco packages can be. Bright blue and green like iPods, long and slender packages that look like lipstick boxes, attractive flavouring and shiny packages with alluring names: a package is a mini-billboard, that is still allowed even in nations with comprehensive advertising bans, and that is carried by the smoker, being shown to friends on repeated occasions.
Plain packaging is the logical extension of an advertising ban to protect our youth and our populations, and brings a bit of truth to the world of tobacco. It forces a deadly product to be sold in a box that represents accurately the harm in can create, instead of being in a shiny box that promotes an attractive lifestyle and positive values.
Plain packaging has now been in place for over two years, and we have seen smoking rates dive in Australia, as well as quit line calls rise, the average age of initiation to smoking rise (and crucial indicator, since most smokers start as children and smokers that start early have a harder time quitting) and support for the measure grow. The industry will work hard to mask this success, but it is an obvious victory for public health to anyone willing to look at proper data. Even more promising, a series of countries have are now considering plain packaging or plan to introduce it – Norway very recently, the UK, Ireland, France, New Zealand. While we have yet to see them implement it, such strong statements should give hope and inspire more countries to take steps towards plain packaging. The data from Australia is clear: plain packaging works.
As we enter an important year for global development and health, let’s not forget an important battle – that is far from won. Strong, clear and progressive anti-tobacco policies are the logical thing to do and the right thing to do. The need is great and the evidence is there. But even so, we should not think this will ever be an easy fight.
In the battle against tobacco, advocates have long referred to the scream test: if the industry screams high and loud, then the measure will likely be effective and save lives. For plain packaging, never has the industry screamed louder. We should all take note, remain focused and make sure we continue to make progress in this important global effort.
Dr Genevieve Bois trained as a doctor in Montréal, Canada, and is currently working in tobacco control, as the spokesperson for the Québec Coalition for Tobacco Control, and as YP-CDN Community Director. She spent a one-year with the Copenhagen School of Global Health working on projects for the NCDs unit, but also involved curriculum development for pre-departure training and global health ethics. Geneviève is passionate about NCDs, building healthy cities and using the urban environment to influence health. She is the past Vice-President of Internal Affairs of the world’s largest medical student, the International Federation of Medical Students’ Associations (IFMSA).