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Behavioural issues in chronic and communicable diseases


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  • 1. Behavioural Issues in Chronicand Communicable Diseases By Dr Nik Nor Ronaidi bin Nik Mahdi
  • 2. • Question: Critically discuss the strategies of multi- national tobacco companies in promoting smoking behaviour particularly in developing countries. To what extent can the state and the community contest the power and influence of tobacco companies. Illustrate your discussion with the history of the operation of tobacco companies in Malaysia.
  • 3. Content• History of tobacco use• Epidemiology of tobacco use• Tobacco industry efforts to thwart effective tobacco control• Conclusion
  • 4. History of tobacco
  • 5. History of tobacco• 6000 BC - Tobacco began growing in Americas.• Around 1st century BC, American natives began finding ways to use tobacco (smoking, chewing and in enemas)• Tobacco was credited with almost miraculous healing powers and was used by the natives of America as remedy for aches, pains, snake-bite, abdominal and heart pain, chills, convulsions, epilepsy, skin disease and fatigue, among other ailments
  • 6. History of tobacco• 1492 – Christopher Columbus discovers tobacco smoking and takes it to Europe• 1612 – Tobacco first grown commercially in North America (Jamestown, Virginia)• 1865 - The first commercial cigarettes (hand rolled cigarettes) were made by Washington Duke → sold to soldiers at the end of the Civil War
  • 7. History of tobacco• 1881 - James Bonsack invented the cigarette- making machine → cigarette smoking became widespread. – He went into business with Washington Duke’s son, James “Buck” Duke. – The first brand of cigarettes were packaged in a box with baseball cards and were called Duke of Durham.• Buck Duke and his father started the first tobacco company in the U.S called American Tobacco Company → largest and most powerful tobacco company until the early 1900’s
  • 8. History of tobacco• In early 1900’s, several other companies were making cigarettes.• In 1902 Philip Morris company came out with its Marlboro brand.• The wars were good for the tobacco industry. – Soldiers overseas were given free cigarettes every day – Cigarettes were also being marketed to women since they became more independent during WW II – Since WW II, there have been six giant cigarette companies in the U.S. [Philip Morris, R.J. Reynolds, American Brands, Lorillard, Brown & Williamson, and Liggett & Myers (now called the Brooke Group)].
  • 9. History of tobacco• 1964 - the Surgeon General of the U.S. ( the chief doctor for the country) wrote a report about the dangers of cigarette smoking →nicotine and tar in cigarettes cause lung cancer.• 1965 - Congress of the U.S. passed the Cigarette Labelling and Advertising Act→ every cigarette pack must have a warning label on its side stating “Cigarettes may be hazardous to your health.”• 1971 - Tobacco companies were not allowed to advertise cigarettes on television or radio.
  • 10. History of tobacco• 1980’s - the tobacco companies had come out with new brands of cigarettes with lower amounts of tar and nicotine and improved filters to keep their customers buying and to help reduce their fears.• 1980’s - governments, and private companies have begun taking actions to restrict cigarette smoking in public places.• 1984 - Congress passed another law called the Comprehensive Smoking Education Act → cigarette companies had to change the warning labels on cigarette packs every three months. – four different labels created to rotate.
  • 11. History of tobacco• State taxes on cigarettes have also increased• As it becomes more difficult for tobacco companies to sell their products in the U.S., they are looking outside.• For the last two decades, tobacco production is declining in the developed countries• On the contrary, tobacco production in the developing world is consistently increasing.• U.S. tobacco companies are now growing tobacco in developing countries such as Africa, India, Pakistan, Philippines, Thailand, and Indonesia.• Fifty percent of the sales of U.S. tobacco companies go to Asian countries, such as Thailand, South Korea, Malaysia, the Phillipines, and Taiwan.
  • 12. Epidemiology of tobacco use
  • 13. Epidemiology of tobacco use• Since at least the colonial era, tobacco has been a popular commodity in US, with tobacco use increasing almost exponentially from the 1800s to the mid-1960s• The invention of the cigarette fueled this dramatic rise in tobacco consumption, and cigarette smoking quickly outpaced the use of any other form of tobacco product (chewing tobacco, cigars). Why? – cigarettes served as a more efficient vehicle for the absorption of nicotine – less expensive form of tobacco
  • 14. Epidemiology of tobacco use• The number of adult smoker increased almost exponentially until its peak in 1963• This growth in consumption was driven largely by: – mass production of cigarettes; – the mildness, packaging, addictiveness, and convenience of the product; – glamorization of smoking in movies and on television; and – persuasive advertising campaigns
  • 15. Epidemiology of tobacco use• Tobacco consumption among Americans have greatly reduced since the publication of the first Surgeon General’s report on the harmful effects of cigarette smoking in 1964.• By 1983, the annual per-capita consumption of cigarettes had declined approximately 20% from the 1963 level to 3,494 cigarettes per adult;• By 2004, it had declined an additional 49% to 1,791 cigarettes• The prevalence of adult cigarette smoking also had declined to half in 2005 as compared to 1965.
  • 16. Epidemiology of tobacco use• Four stages of tobacco epidemic: – Stage 1: • Low prevalence (below 20%) of cigarette smoking, principally limited to males, with no apparent increase in lung cancer or other chronic diseases caused by smoking. – Stage 2: • increases in smoking prevalence to above 50% in men, early increases in cigarette smoking among women • increasing burden of lung cancer and other tobacco- attributable disease in men • Tobacco control activities are usually not well developed, the health risks of tobacco are not well understood, and there is relatively low public and political support for the implementation of effective tobacco control policies.
  • 17. Epidemiology of tobacco use– Stage 3: • Marked downturn in smoking prevalence among men, a more gradual decline in women • The burden of smoking attributable disease and death continues to increase.– Stage 4: • Marked downturn in smoking prevalence in both men and women. • Full damage caused by cigarettes
  • 18. Tobacco industry efforts to thwart effective tobacco control
  • 19. • The tobacco companies are among the world’s most sophisticated and successful marketers.• They spend billions of dollars to promote their deadly products, prevent governments from protecting their people and mislead tobacco users and potential tobacco users
  • 20. Political influences• In US, the tobacco industry spends millions of dollars trying to influence public policy.• Occurs through quiet, behind the scenes, insider strategies.• It makes major contributions: – to elected officials and political parties, – payments to governments to support infrastructure such as mass transit – large investments in sophisticated public relations campaigns – gives money to civic, educational and charitable organisations• In turn the politicians help the tobacco industry.
  • 21. Political influences• Eg: In an attempt to boost its market share in Indonesia, Rothmans Indonesia sold 5 % of its equity to Mr Sudwikatmono, a cousin of President Suharto, whose family controlled huge sections of the Indonesian economy and whose patronage is a virtual guarantee of commercial success• What about Malaysia?
  • 22. • Malaysian scenario: – While the government has pledge its commitment to promote healthy living and discourage smoking, on the flip side, they have opted to engage and collaborate with tobacco companies in promoting anti-smoking campaigns – Health activist are questioning the government half hearted measures in tobacco control and the tobacco industry’s involvement in the orchestration of anti-smoking campaigns which contrastingly leads to an increasing prevalence of smokers – Malaysia’s history of tobacco control is pockmarked with the failures of adopting of an ad hoc policy and collaborating with tobacco companies , favouring industry guidelines over legislations and protecting tobacco cultivation – Government also issuing licenses to local companies to produce cheaper local cigarretes (e.g: John, Saat, Bromax) (FOMCA’s Position Paper on Tobacco Control in Malaysia, 2006)
  • 23. • Malaysian Scenario – In January 1982 the Malaysian government took another step forward in tobacco control and announced a ban on the direct advertising of imported brands over RTM and pushed back the advertising time for locally manufactured brands till after 10 pm. • Direct lobbying of top level officials in several ministries, pushing for support for its counter-proposal and providing arguments against either a complete ban or a more punitive restriction on cigarettes. The CMTM received assurances the proposal would receive support from the Ministries of Trade and Industry, Primary Industries, and Agriculture. • It only take the industry just five months to defeat the original decision.
  • 24. • Malaysian scenario: – Regarding the issue of indirect advertising and sponsorship, tobacco companies gain support from the very top leadership in Malaysia including the King, the Prime Minister, and cabinet ministers. • discourage efforts to ban indirect advertising in Malaysia. – E.g: • Marlboro’s sponsorship of motor racing events, for example, assisted the Prime Minister in his quest to bring Formula 1 to Malaysia. The Marlboro Malaysian Grand Prix in April 1997 was flagged off by the Prime Minister. In 2001, Formula 1 racing was held in Malaysia for the first time. • In the mid 1990s RTM was earning about 40% of its advertising revenue from tobacco companies and the Minister indicated the station could not do without tobacco money.
  • 25. Economics arguements• Tobacco industry often argues that tobacco control will harm the national (or regional) economy.• They claim that tobacco farming, manufacturing, distribution and sale constitute a vital part of the economy and that if smoking is eliminated, the country will suffer substantial job losses, incomes will fall, tax revenues from tobacco will disappear, and international trade will suffer.
  • 26. Economic arguments• In the developing world, tobacco companies actively promote the economic benefits of tobacco farming to local economies and farmers.• The industry-sponsored tobacco farmers’ lobby group, the International Tobacco Growers’ Association, served as a front for lobbying developing countries at WHO.• Exaggerate the economic significance of tobacco growing for the farmers : – the global price of tobacco is relatively stable compared with other crops. – In addition to the cash revenue, strong support in kind is also provided by the tobacco industry in the form of material and advice. – the industry often gives farmers loan. – other crops may cause farmers problems with storage, collection and delivery. Tobacco is less perishable than many crops, and the industry may assist with its delivery or collection; by contrast, late collection, late payment, and price fluctuations may blight other crops.
  • 27. Global Tobacco Control website(
  • 28. Economic arguments• Does increase in cigarettes taxes promote smuggling activities?
  • 29. Economic arguments• Taxation is one of the most effective measures for reducing tobacco consumption.• The tobacco companies oppose tax increases. More and more, they rely on the argument that higher taxes are an incentive for smuggling. – increased cigarette taxes will reduce legal sales, but not total sales (legal and illegal sales combined) – increased taxes will lead to increased smuggling, resulting in less revenue for governments• Both Canada (1994) and Sweden (1997) have reduced taxes on tobacco in response to concerns about smuggling.
  • 30. Economic arguments• According to the World Bank, the experience of a large number of high-income countries shows that, even in the face of high levels of smuggling, tax increases bring increased revenues and reduce cigarette consumption (Jha P, Chaloupka F. Curbing the epidemic: governments and the economics of tobacco control. Washington, USA: World Bank, 1999)• Tobacco industry benefits from smuggling activities: – smuggling stimulates consumption both directly (through the street sale of cheap cigarettes) and indirectly (through pressure to lower or keep down taxes) – the treat of smuggling has also been used to avoid trade barriers or to force open new markets.
  • 31. Economic arguments• As expected, tobacco companies are actually involved in smuggling activities: – Since 1997, there have been several court cases and official investigations in different part of the world which accused the industry of supplying the smuggled cigarettes or at least of being aware of the illegal destination of their products. E.g.: • A former BAT executive was found guilty by the Hong Kong’s High Court for his role in his role in an operation that smuggled cigarettes into China. • In 1998, a major tobacco company was convicted for actively breaking the law to assist in a smuggling operation. • An affiliate of RJ Reynolds International pled guilty to charges of helping smugglers illegally reroute export cigarettes into Canada.
  • 32. Allies, third parties and front groups• Fighting tobacco is not a one to one battle• The tobacco industry has many business allies and third parties with which it works to block implementation of effective tobacco control legislation and programmes.• Allied and third-party industries that have opposed tobacco control include: – hospitality – gambling and gaming – advertising – Packaging and transport – chemical production – tobacco retailing – agriculture and tobacco growers – labour unions – investment advisers – recipients of tobacco sponsorship and research funds
  • 33. Marketing strategy• Explore market in developing countries• Tobacco companies provide benefits to the retailers – sales incentive programmes – promotional discounts – attractive display units – incentives for prominent placement products in their shops
  • 34. Scientists and researchers• Tobacco companies realized the important role of scientists and researchers in developing public policies for tobacco control.• Tobacco industries are either: – Funding research to produce favourable results, to suppress unfavourable findings, and to give alternative explanations for diseases associated with tobacco use – Attacking scientist and researchers by portraying them as extremist, unqualified and politically motivated, denigrating and humiliating them to superiors, publishers and the public, bringing lawsuits, and working to cut off funding.
  • 35. Scientists and researchers• E.g: – In 1991, Glantz and William Parmley published their reseach in the journal Circulation, which concluding that secondhand smoke caused approximately 53,000 nonsmoker deaths a year, including 37,000 from heart disease. • Consultant Larry Holcomb wrote to the Circulation paper arguing that Glantz and Parmley drew stronger conclusions from the epidemiological studies than was warranted and that the studies failed to control for confounding variables like diet. • Walter Decker, also wrote Circulation arguing that the studies Glantz and Parmley considered were methodologically flawed and criticized them for including studies published in foreign languages.
  • 36. Promoting and Advertising• Cigarettes are the most heavily advertised product in the U.S. (4 billion dollars a year)• In 2000, British American Tobacco (BAT) and Japan Tobacco International (JTI) were the first and third largest advertisers in all Malaysian mass media, respectively, spending some 160 million Malaysian Ringgit (Audit Bureau of Circulations News, March 2001).• The purpose of cigarette ads and promotions: – to make sure smokers keep smoking – get people who quit to start smoking again – to increase the number of cigarettes people smoke each day – encourage women and young people to start smoking
  • 37. Promoting and Advertising• Promotion: – sponsor sporting, art, and music events – scholarships (e.g: British American Tobacco Malaysia Foundation Scholarship) – donations to organizations (e.g: National Association for the Advancement of Colored People, the National Urban League, and Goodwill Industries)• The advertisements are very successful• According to U.S. Surgeon General, every day 3,000 teens smoke their first cigarette• Examples of popular cigarette ads among people: – R.J. Reynold’s advertises Camel cigarettes with the cartoon figure “Joe Camel.” – Philip Morris’ Marlboro cowboy ads • one of the cowboys pictured in Marlboro ads, Wayne McLaren, died of lung cancer. He died in 1992 after smoking for 25 years.
  • 38. • Malaysian scenario: – In January 1971, the Singapore government imposed a complete ban on all forms of cigarette advertising – Singapore then made overtures to the Malaysian government to also ban cigarette advertisements over RTM, which could be received by Singaporeans – The Malaysian government brought together the several relevant ministries, health professionals, and the tobacco industry to discuss a proposal to ban tobacco advertising – The industry asked for ‘‘…additional time to study the issue before making alternate proposals’’ – The decision was postponed until for six years.
  • 39. Conclusion
  • 40. Conclusion• Fighting against tobacco industry is very challenging – Involved high political influences from top leadership – Involved so many allies and third parties – Efforts from tobacco companies to counter attack• The tobacco industry is not and cannot be a partner in effective tobacco control.• The industry’s fight against tobacco control in Malaysia is consistent with its global strategies.
  • 41. THANK YOU
  • 42. References• R.C. Jiloha (2008), Tobacco Use: Health and Behavior, New Delhi, New Age International (P) Limited.• Richard J. Bonnie, Kathleen Stratton, and Robert B. Wallace (2007), Ending The Tobacco Problem: A Blueprint For The Nation, Washington DC, The National Academic Press.• Judith Mackay and Michael Eriksen (2002), The Tobacco Atlas, London, The Halfway Press.