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Canada: pharmacytobacco sales tomentally ill peopleThe mental health community is finallywaking up to the reality of mentally illpeople being disproportionately affectedby the tobacco epidemic. In Canada,about one in five people are affected bymental illness, and an estimated 50% ofthem (and up to 90% of schizophrenics)are smokers. They are also less likely toquit than the general population. For thisgroup, too, the high cost of smoking oftenmeans that regular meals, family respon-sibilities, stable housing and other neces-sities are relinquished, leading to aninevitable exacerbation of a downwarddrift in society, with more social illsfurther marginalising them. To retainsmokers and recruit new ones the tobaccoindustry has conducted extensiveresearch on factors impacting on thementally ill, who may be seen as an easytarget - industry documents describethem as ‘‘anxious’’, ‘‘psychologically vul-nerable’’, ‘‘angry’’, and ‘‘least likely toquit,’’ to name only a few.

There are virtually no cessation pro-grammes designed to accommodate thespecial needs of severely mentally illsmokers and the barriers to their quittingare perceived by many as insurmounta-ble. Despite a body of evidence thatcessation treatment is effective, themajority of mentally ill people do notaccess effective, individualised treatment.Isolated, positive reform has occurred,with mental health groups deciding torefuse tobacco industry funding and awidespread trend towards smoke-freehospitals and healthcare facilities.

However, in some Canadian provinces"power walls" of cigarette packs in retailoutlets remain a powerful marketing tool(see Canada: point of sale win – again.Tobacco Control 2005;14:78-79). Theirimpact on the mentally ill may well beamplified, due to cognitive deficits,impaired decision-making capabilities,diminished motivational and volitionalassets, as well as other challenges inherentto mental illness. It has been widely

demonstrated that the mentally ill usetobacco to self-medicate negative moodstates, symptoms of schizophrenia, cogni-tive deficits, depression, as well as side-effects of medication. As a result of thisvulnerability, mentally ill people face a realrisk of a perpetuation of tobacco’s alreadydevastating impact.

To add insult to injury, in someCanadian provinces pharmacies still selltobacco. In these, power-wall tobaccomarketing may be particularly proble-matic for the mentally ill as the pharmacyis the ‘‘place of health’’ most mustfrequent to collect their medication. Theconflicts between the dual roles of suchpharmacies - counselling on cessationand selling tobacco - has resulted inseven provinces and territories banningthe sale of tobacco in pharmacies by law,with an additional ban, in Quebec, by thepharmacists’ own professional body inresponse to a complaint by a member ofthe public.

In 2005, I filed a formal complaintagainst every tobacco-selling pharmacistand pharmacy in Alberta. There seemedno reason why the Quebec ruling (andthe ethical stance in the seven otherprovinces and territories) should not alsoapply to the remaining provinces withpharmacy tobacco sales, includingAlberta. There was a general sentimentamong pharmacists to help protect thepublic and not to support tobacco sales;and two large-scale surveys demonstratedoverwhelming support for a ban inAlberta’s pharmacies. However, the com-plaint was rejected. It was followed by asecond, similar complaint naming fivespecific pharmacies selling tobacco.

It took more than a year before aresponse was received. A legal opinionhad been sought by the regulatory bodyand the listed pharmacists had a chanceto provide rebuttals. These included:‘‘tobacco sales are legal in Alberta’’,‘‘tobacco purchases are a matter of choicewhich the pharmacist should respect’’,‘‘decisions are made on corporate level,and not by the individual pharmacist’’and ‘‘pharmacists do not profit fromtobacco, and have no vested interest inthe product’’. However, the spirit of theoverall response was not uniform: onepharmacist removed tobacco from hispharmacy. The complainant was notifiedthat the issue was closed (no disciplinaryaction followed) and that it was wrong touse the disciplinary route as an indirectmeans to achieve a specific public policygoal.

The differing interpretation of a criticalethical issue among Canadian provincesremains perplexing, though the invitationof Alberta’s pharmacists to jointly seeksolutions is welcome. The only remaininghope is for Alberta’s government to banpharmacy tobacco sales, an initiative thepremier supported in pre-election sur-veys. However, the legislative wheels turnslowly, and in the meantime, mentally illpeople west of Ontario, like the generalpopulation, remain exposed to this mostincongruous form of tobacco marketing.

CHARL ELSPhysicians for a Smoke-Free Canada, Alberta,

Canada; cels@ualberta.ca

USA: not so pretty inpinkPink is a favourite colour of marketerstargeting the coveted purchasing power ofgirls and young women. It is used to selleverything from mobile telephones to golfclubs and pop music. Tobacco companieshave also cashed in on this stereotypicalcolour with products such as PinkDreams cigarettes. ‘‘The name alone hashead-spinning implications. Thoughtswhiplash from bubblegum-n-Barbie toprovocative porn, depending on yourage, gender, and mindset,’’ notes theAmerican non-profit organization,Shaping Youth, which aims to counternegative marketing and media aimed atchildren.

Not only is the outer packaging of thePink Dreams pack coloured pink, but thecigarette itself is wrapped in pink paperand topped with a gold filter. Described asa super-premium product, this ‘‘fashion-able cigarette’’ comes ‘‘beautifully gift-boxed in a pink foil package’’ and ‘‘offerspure pink smoking enjoyment to today’ssophisticated female adult smokers.’’ Thecigarettes are imported into the UnitedStates by Kretek International (KI). KIdistributes more than 500 brands oftobacco products from around the worldthroughout the USA and Canada. Thecompany has positioned itself as leader inthe specialty cigarette market.

The popular US-based websitewww.punkrockdomestics.com, a discus-sion board for girls and young womenseeking counter-culture household tips,features a forum about cigarettes.Website members had this to say aboutPink Dreams cigarettes:

All articles written by David Simpsonunless otherwise attributed. Ideas anditems for News Analysis should be sentto: d.simpson@iath.org

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‘‘i heard about these cool ciggs calledP I N K D R E A M S h a s a n y o n etried…they come in a pink tin, androlled with pink paper and have agold colored filter...its [sic] the packa-ging that kills me!’’‘‘My favorite color is pink. I mighthave to go check out the smoke shopnext week’’‘‘My friend got a pack of those and letme bum one or two.. I was just excitedto be smoking a pink cigarette!’’

It is not possible to determine whetherthese comments were posted by realwomen talking about real experiences,or by women who were compensated bythe cigarette manufacturer to post posi-tive messages on this female-targetedwebsite. Promoters of the Pink Dreamsbrand could have easily employed youngwomen to join female-targeted websitesto introduce the brand to other potentialcustomers—‘‘cigarette girls’’ are alreadyan established practice in bars and night-clubs. Or perhaps someone with a com-mercial interest in selling the cigarettessimply invented them.

The colour pink is also the iconic badgeof global breast cancer awareness cam-paigns, with their distinctive pink ribbonsand associated fundraising products.Given the obvious similarities betweenPink Dreams packaging and pink ribbonproducts, it is possible that the manufac-turers are capitalising on the emotionalconnection many women feel to thiscause related marketing. Or perhaps itintends to capitalise on the popularityof the Grammy award-winning USsinger/songwriter Pink, real name AleciaMoore, who has sold more than 25million albums since coming to promi-nence in 2000. Regardless of the precise

motivations involved, this is anotherexample of a tobacco company appro-priating feminine imagery to sell itsdeadly products to young women.

BECKY FREEMANUniversity of Sydney, Australia;bfreeman@health.usyd.edu.au

Belgium: taking a leadin EuropeFor many years, the corridors of power inBrussels, the Belgian capital, seemed tobe peopled almost exclusively by tobaccolobbyists. It was not the Belgian parlia-ment that they stalked, but the EuropeanCommission, secretariat of the EuropeanUnion (EU). Their mission was to try toprevent the development of EU directivesthat would in due course require eachmember state to enact effective tobaccocontrol legislation in its own parliament.Sometimes the industry lobbyists’ stalk-ing would turn into a downright stam-pede, on occasions, the overwhelmingmajority of people packing out committeerooms would turn out to be doing theindustry’s dirty work. Now that the EUhas been expanded to 27 countries, it iseasy to see why so much effort waspoured into the resistance movement,and conversely, how much is owed topoliticians and officials who fought it allthe way on behalf of health.

Around the world, from Canada toAustralasia, Brazil to Thailand, pioneeringhealth ministries have researched,designed, tested and introduced variousseries of graphic warnings. These havebeen busy playing their part, millions oftimes a day, in eroding the lingering air ofluxury and bravado that manufacturersstill try so desperately to convey to theircigarettes via pack design and whateverother promotional tricks they can getaway with.

Belgium never used to be high on anylist of tobacco control success or determi-nation by its government, but today it hasearned a refreshingly different connota-tion in public health circles - top of theleague in Europe, in fact. Last December,it made cigarette manufacturers printgraphic health warnings on tobaccopackaging, the first EU member state todo so. The United Kingdom is to followsuit later this year and Romania in 2008.However, considering the scale of thebattle that was fought to add such animportant element to European tobaccocontrol policy, whose final clearance wasissued more than three years ago, it isextraordinary how slow other EU stateshave been to do the same.

Perhaps the government’s zeal is catch-ing: recently a school in the busy port city

of Ostend was the centre of a nationalmedia frenzy when its plan to force pupilscaught smoking to wear a badge waspublicised. The badge, whose messagewas along the lines of, ‘‘This is what mylungs look like now, for all I care,’’ alsopictured a full colour, graphic image of asmoker’s lungs in an apparently advancedstate of disease. However, following pro-tests around the country, the scheme wasdropped. There were, of course, soundarguments against an approach thatpointed the finger of blame and shameentirely at the unlucky young smokers,but the new health warnings have thepotential to do the same education job onall smokers, children and adults alike,smoking openly or in secret. The chal-lenge is to keep researching images thatwill maximise the effect.

European Union:parliament hosts BATstuntJust how badly does a company have tobehave to be denied special access topoliticians elected to safeguard theirvoters’ health and other interests?Despite a long record of doing its utmostto prevent effective tobacco control poli-cies in Europe, British American Tobacco(BAT) has been allowed to hold a lobby-ing event on its "corporate social respon-sibility" (CSR) programme in theEuropean Parliament. Using the tiredold rhetoric that politicians and parlia-mentary officials should have learned todecode long ago, BAT billed the event,held in January, as a "stakeholder dialo-USA: Pink Dreams

Belgium: one of the new graphic health warningsin the first European Union member state toimplement them.

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gue" and part of its 2006 social reportingprocess.

To try to make politicians and othersthink that everyone, like it or not, is a"stakeholder" in its wretched business, isone of its most invidious tricks.Politicians worth their salt, not to men-tion salaries, can surely see through suchcorporate sophistry? Moreover, they can-not have failed to hear about the widelypublicised evidence from BAT’s owndocuments revealing the true nature ofits CSR and youth education pro-grammes. Nor does it take much thoughtto work out how the company justifiesspending its shareholders’ money on suchpublic relations nonsense. Obviously, itmust be aimed at mitigating what thepoliticians might otherwise do to reduceconsumption, the only proven way toreduce future tobacco induced disease.

Commendably, Cancer Research UK, byfar Europe’s largest health charity, cameout strongly against the decision. Dr JeanKing, its director of tobacco control, said,"There is a mountain of evidence thattobacco companies cannot be trusted todeliver on their promises of social respon-sibility." She said her organisation wasgravely concerned by the way tobaccocompanies seemed to be attempting toinfluence governments. This concern isechoed by tobacco control advocatesworldwide, who fear that victories forhealth in recent years may breed acomplacency that allows the industrynot just to live with the FrameworkConvention on Tobacco Control, but tothrive under it. For BAT, being treated as"normal" by the European parliamentmust rate as a major step towardsrenewed normality.

Hong Kong, China:industry’s loss of faceand smokeAmong the surprises of Hong Kong, longestablished as a byword for free trade, hasbeen its tendency to be a place where thetobacco industry stubs its corporate toe,and sometimes even comes a real cropper.From an adventure playground for youngtobacco advertisers in the early 1980s -the companies must have rated it the lastplace on earth to stop their energeticentrapment of young people in thenicotine web - it rapidly turned into apublic health model for the region. If theindustry’s overall judgement was ofteninaccurate, some of its strategies werewildly off the mark. In challenginggovernment tobacco control plans, forexample, the tobacco companies’ use ofmassive public relations blitzes, tired oldrhetoric and patronising, see-though

sophistry, as well as bogus "experts" flownin from around the world, cut little icewith legislators; and the blustering,threatening tone of testimony offered tothe fledgling legislative council almostcertainly did the industry more harmthan good.

To public health workers in HongKong, therefore, it was all the moreamusing to see the tobacco industry makeanother big mistake there recently. Theoccasion was the trade exhibition TobaccoAsia Expo, held in January at the gleam-ing new AsiaWorld-Expo centre at HongKong’s international airport. Followingthe participation of a health representa-tive in a similar show some years ago,such get-togethers are now billed asstrictly tobacco industry-only, privateshows. Perhaps this strictly enforcedsecrecy contributed to the mistake.

While the convention and exhibitioncentre in Hong Kong’s Wan Chai districtmight have been the obvious venue forsuch a large trade fair, it was rejected onaccount of its strict smoke-free policy.The organisers were aware that legislatorswere debating smoke-free legislation forall workplaces, but either thought itwould be delayed even longer than theeventual marathon of six years, or that itwould be sufficiently watered down toallow smoking areas. But the new law,banning smoking in all workplaces exceptcertain bars and leisure venues, came intoforce just a few weeks before the start ofevent (see Hong Kong, China: bad atmo-sphere for public health. Tobacco Control2007;16:3–4). Commenting on the factthat AsiaWorld-Expo was now a totallysmoke-free venue, one of the organisers,Glenn John, editor of Asia Tobacco maga-zine, was memorably quoted as saying,"It’s kind of a drag." That’s just the point,Mr John: for the health of the staff thathave to work there all day, nowadays it’sno drag at all.

USA: kids chew overmovie ideasThe official tourist website of Wyoming,set right in the middle of the USA, says itis the ’cowboy state’, and home to moredeer and antelope than people. But to oralor "spit" tobacco manufacturers, there areenough people, especially young people,for it to be a lucrative market. Healthworkers believe that part of the problemhas been the promotion of the product as"smokeless tobacco", with the implicationthat it is safe. Wyoming has laggedbehind most other states to combat theproblem, which is now being addressedmore seriously.

As part of the state health department’s"Through with Chew" week in February,

children who apparently might usually sitat home at the weekend, some with achewing tobacco tin readily to hand, havebeen recruited to an unusual programme.Working with AnimAction, a Los Angeles-based outfit that helps young peopledevelop artistic and creative skills throughdevising and making animated films,more than forty school children attendeda day long workshop in January to learnmore about oral tobacco and then deviseanimated films to pass on vital informa-tion about its dangers to their peers.

Reportedly, children who already knewthat oral tobacco caused mouth cancerhad little or no idea of its other dangers,such as its association with cancer inother organs though the ingestion oftobacco tainted saliva. Armed with amuch more thorough knowledge, theyset about their film work in small teams,knowing that the storylines and designsjudged most effective would be made intoreal animated movies and aired on localtelevision. Perhaps tomorrow’s cowboyswill be more like the film-makers whomake them famous than their tobaccospitting predecessors.

South Korea: packdesign bombshellThe former state-owned tobacco mono-poly, now known as KT&G and fullyprivatised in 2002, dominates at homewith 72% of the market, and is rapidlyexpanding abroad, especially in theMiddle East and Central Asia, with aneye on the rich pickings to be gained inRussia and China. Since the drab days ofstate ownership, it has learned fast fromits big, international competitors, and amarketing extravaganza at the end of lastyear showed just how far it has come inslick and sophisticated design.

Unusually, one of KT&G’s leadingbrands, with about 7% of the market, iscalled Raison D’Etre, and has no Koreanname. This fact, and the name itself, theFrench phrase, often borrowed for usein English and meaning a reason for

USA: children at work on educational filmstoryboards as part of Wyoming’s "Through withChew" week.

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existence, suggest it is aimed at young—very young—urban, western-leaning con-sumers. Recent marketing developmentsamply confirm this.

Since its launch in 2002, Raison - as itis typically known - was already asso-ciated with clever presentational ploys.The main image on the pack was a cat invarious colours, including blue and green,with regular variations such as a FatherChristmas robe at the end of the year.New packs would appear in time to cashin on the country’s holiday seasons andbe on sale for about two months. LastDecember, however, the seasonal market-ing splash moved into a different league.

Gone was Raison’s cat, to be replacedwith a variety of highly stylish and colour-ful designs, including, by the company’sproud admission, Indie band, B-boy andX-sports music references, as well asgraffiti. Many are not just appealing toyouth, but probably only understood bythose young enough to put their bodiesthrough the contortions required in SouthKorea’s most fashionable discos.

Unlike the brand’s name, the graffitiare in Korean, and plug into a rap lexiconprobably more foreign than French orEnglish to any South Korean pastadolescence, riddled with teen desire forindividuality and rejection of the uncom-prehending world of stuffy adulthood.Each ends with the catchphrase thattranslates as, "It is the reason why I live".

Tobacco ads are banned on billboardsand in news media in South Korea, withthe exception of up to 60 per year inmagazines with adult readerships. Thuspack design, which works at the time ofsmoking as well as at the point of sale,together with internet promotions, are

obvious ways to go to aggressively pro-mote cigarettes and recruit new, youngsmokers. It clearly works; apart from itshigh brand share, Raison’s popularityamong teens speaks volumes.

The maximising of pack design asadvertising will no doubt become moreprevalent in all countries that fail toimplement tough, graphic health warn-ings that destroy the highly misleadingpromotional potential of brands likeRaison. Public health law makers haveto stop precocious advertising that con-nects with rebellious teenagers seeking toexpress themselves - "It is the reason whyI live." Otherwise, for many of the youngpeople who respond, it may one day bethe reason why they die.

Nepal: ad peakovershadows lawdraftersSince the government ratified the WorldHealth Organization’s FrameworkConvention on Tobacco Control (FCTC)last November, Nepal has seen a massiveincrease in tobacco companies’ promo-tional activities.

The big cigarette companies - SuryaNepal, a subsidiary of India’s ITC andBritish American Tobacco, and SetiCigarette Factory, a subsidiary of PhilipMorris—have greatly increased theirspending in all national newspapers andweekly, fortnightly and monthly maga-zines, as well as on large billboards inshopping malls, department stores and inpublic places. Health advocates estimatethe increase in spending to be at leasttenfold.

In addition, the companies have beensponsoring musical nights at five-starhotels in the capital, Kathmandu, as wellas in Biratnagar, the country’s secondlargest city, near the Indian border in thesouth, and in the western city of Pokhara,one of Nepal’s most popular tourist desti-nations. With names such as Surya LightsRhythm Nites and Surya Lights BollywoodTemptations: Freedom of Lights MusicalBroadway, there is no doubt as to whichage groups are being targeted. In additionto promoting its namesake cigarettebrand, Surya Nepal has also been sponsor-ing events in the name of other brands,including Shikhar Lights and ShikharFilter Kings, including one to exploit the

biggest Hindu festival, Shivaratri, celebrat-ing the birth of Lord Shiva, and anotherclearly aimed at youth and girls.

This huge increase in tobacco promotionmay be partly designed to take advantageof the lengthy process of drafting andimplementing the new law - local sourcessay government bureaucracy is notoriouslyslow. However, another likely explanationis the familiar tactic of the tobaccoindustry under threat, namely makingthe news media, hotels and other busi-nesses more dependent on tobacco adver-tising revenue, to increase pressure for anon-comprehensive tobacco promotionban. Health advocates have made specialrepresentations to the government appeal-ing for swift action and catch-all legisla-tion, and they have even appealed to thecompanies, but hold out little hope forgood news from either.

South Korea: some of the Raison D’Etre packs onsale over the Christmas and New Year holidayseason.

Nepal: a billboard promoting Surya Litescigarettes, made by a BAT subsidiary. The brandsponsored music nights in five-star hotels.

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