Worldwide news and comment
Worldwide news and comment Free http://orcid.org/0009-0002-4939-0030Ruth Canty1,2 1Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia 2NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, The University of Queensland, Brisbane, Queensland, Australia Correspondence to Ruth Canty; ruth.canty{at}menzies.edu.au Statistics from Altmetric.com Request Permissions If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways. Public policyTobacco industryAdvertising and PromotionAll articles written by Ruth Canty unless otherwise attributed. Ideas and items for News Analysis should be sent to [email protected]: Tobacco 10-Packs: A Failed Deal Between BAT/PTC in Pakistan and SudanBritish American Tobacco (BAT—and its subsidiary Pakistan Tobacco Company, PTC) have a long and well-evidenced history of deception and influencing policies. Additionally, within Pakistan, there is a history of BAT gaining the support of British diplomats to influence the policy process. In November 2023, BAT/PTC sought permission from Pakistan’s Ministry of Health, to manufacture and export 10 packs (also referred to as kiddie packs due to their affordability and easy access to children) to the war-torn country of Sudan. Both Pakistan and Sudan are Parties to the WHO Framework Convention on Tobacco Control (FCTC). Aligned with Article 16 of the FCTC, Pakistan has regulations against producing packs containing less than 20 cigarettes to reduce affordability and prevent child smoking initiation. By engaging in this transaction, both Pakistan and Sudan infringed on FCTC obligations including Articles 5.3 and 16 of the FCTC.The Ministry of Health resisted the industry’s request, and actors in the global tobacco control community sent a letter to the Prime Minister of Pakistan requesting the prevention of manufacturing and exporting kiddie packs to Sudan. The letter was signed by 54 organisations and 60 advocates from 25 African countries. However, due to excessive tobacco industry and political pressure, in July 2024, there was a proposal by Ministry of Health to issue an amendment to the existing Statutory Regulatory Ordinance (SRO) with additional words ‘domestic consumption’. The proposed amendment in the SRO stated, “No cigarette manufacturer shall manufacture, sell or offer for sale, any cigarette for domestic consumption unless they are in packets of at least twenty cigarette sticks.”Previously, BAT/PTC wanted to export 10 packs from Pakistan to the Gulf countries in 2019, but the Ministry of Commerce denied permission. BAT/PTC intended to exploit Pakistan’s ongoing economic/financial struggles to secure this recent US$20.5 million deal by manufacturing and exporting these 10-pack cigarettes to Sudan. However, due to the excessive delay in processing and ultimate denial of this amendment, the Pakistani tobacco control community successfully prevented the materialisation of this order which was ultimately delivered by Bangladesh (another WHO FCTC signatory country in South Asia).Adding the domestic consumption clause raised significant questions regarding the ethics of cigarette manufacturing and the global tobacco supply chain. Prioritising a country’s economic benefit over another’s public health is a repeated practice within tobacco markets, despite the WHO FCTC requirement to consider public health objectives in trade and investment agreements. This case in point merits an inquiry to signpost the tobacco industry’s repeated unethical practices prioritising profits over public health by targeting marginalised communities, and those in fragile, and war-torn zones.The collective appeal from multiple organisations, and tobacco control advocates also highlights the potential harm these packs could cause across the African Continent. It is reported that billions of BAT-produced cigarettes are smuggled every year to Sudan. Besides, extensive research exists implicating BAT of multiple instances of frustrating tobacco control measures in Sudan. Furthermore, in Pakistan, there is a real risk that the 10 packs produced for ‘export alone’ could popularise in local markets due to affordability and easy access to the children. Such unintended outcomes would contradict the stated aim of the regulatory amendment adding to the enormity of the tobacco pandemic in Pakistan.It is vital to note that during this controversy, Pakistan’s FCTC focal person in the Ministry of Health (a government employee) was removed from his position. There is a need to highlight the industry’s undue practices and a need for greater inter-governmental and regional collaboration to disrupt the tobacco industry’s profit-centric practices.Waseem Iftikhar Janjua, Sustainable Development Policy Institute (SDPI), Islamabad, Pakistan, Syed Ali Wasif Naqvi, Sustainable Development Policy Institute (SDPI), Islamabad, Raouf Alebshehy, Department of Health, University of Bath, UK.Switzerland: new tobacco control legislation in SwitzerlandIn Switzerland, the first Federal Act on Tobacco Products and Electronic Cigarettes came into force on 1 October 2024. It has been a long journey since the first public consultation in 2014. As detailed recently in a report published by OxySuisse and authored by ASH USA, Switzerland has a strong tobacco industry presence, weak tobacco control regulations and has not yet ratified the WHO Framework Convention on Tobacco Control (FCTC). The country ranks second to last, in both the European ‘Tobacco Control Scale’ 2021 and in the ‘Global Tobacco Industry Interference Index’ 2023.Following the European Union, tobacco products and electronic cigarettes will finally be removed from food regulations and be regulated through the new federal act, which will harmonise minimum good practices federally. It will include all tobacco products, electronic cigarettes, oral nicotine products and similar products, in addition to banning the sale of these to minors under 18. Enforcement measures include test purchases and penalties.The legislation prohibits radio and television advertising, as well as advertising in public places, public transport, cinemas and sporting events, as well as the distribution of free tobacco products or electronic cigarettes. Tobacco advertising is still allowed at points of sale, in the press, in festivals, on the internet and social media. Where advertising is permitted, mandatory health warnings must be included. Secondhand smoke regulations will be expanded to include electronic cigarettes, and a modest tax will also be introduced on e-cigarettes. New health warnings will be introduced, based on the existing European Union warnings and will include a ban on indicating nicotine, tar or carbon monoxide content.This is an important update to the legislation, although there is still a need for stronger implementation of the WHO ‘ best buys’. For instance, the new law does not yet include the ban on tobacco advertising reaching children and adolescents, which was approved by a referendum in 2022. This amendment is currently being debated in parliament.It is worth noting that the 26 states that constitute the Swiss Confederation can enact stronger local laws to protect from exposure to secondhand smoke (such as banning smoking rooms with service, as in seven cantons) or restrict advertising (such as banning point-of-sale advertising, as in the canton of Valais).This law is a first step towards better tobacco control in Switzerland. Future challenges include increased taxation, plain packaging, reimbursement of nicotine replacement therapy as well as other MPOWER policies and ratification of the FCTC. The powerful and determined opposition of the tobacco industry must be overcome to achieve these public health goals. This will remain difficult as long as the parliament puts trade over health. At the same time, votes and opinion polls show that the population is in favour of tobacco control legislation.Luc Lebon, PhD, manager of the Tobacco Prevention Sector, University Center for Primary Care and Public Health, University of Lausanne.Tobacco-free generation takes off in 20242024 was a significant year for the Tobacco-Free Generation policy. The Tobacco-Free Generation (TFG) is a tobacco endgame policy that prohibits sales of tobacco to people born after a specific date, with the purpose of preventing a new generation of people from starting to smoke while also not criminalising people who are already addicted to nicotine. The year got off to a rocky start, with the repeal of the SERPA legislation in New Zealand/Aotearoa, one element of which was a Tobacco-Free Generation, a move that disappointed many public health advocates around the world. However, by the end of the year, significant advances had been made in several jurisdictions, the US state of Massachusetts, South Australia, and the UK.Since the concept of Tobacco-Free Generation was first considered, several jurisdictions around the world have taken steps to legislate the policy. In 2014, Tasmania in Australia was the first jurisdiction to attempt to introduce a TFG. In 2016, Balanga City in the Philippines was the first city to implement a law to eliminate tobacco sales based on year of birth; however, the measure was overturned in 2018 following a tobacco industry lawsuit. In 2023, in Malaysia, the Generational Endgame component prohibiting sales to people born after 2007 was ultimately dropped from the Control of Smoking Products for Public Health Bill.The town of Brookline, Massachusetts, was the first US jurisdiction to introduce a Nicotine-Free Generation law in 2020, a variation of the TFG which includes all recreational nicotine products. The law was upheld by the state’s Supreme Court in March 2024. People born after 1 January 2000 cannot purchase tobacco or other non-therapeutic nicotine products including e-cigarettes in the town. Following this success, 11 more towns in Massachusetts followed suit by the end of 2024 with a birth date cut-off of 1 January 2004, and on 16 January 2025, a bill was introduced in the Massachusetts Senate seeking to ban the sale of nicotine products in the state of Massachusetts to anyone born after 2005.In September, in South Australia, the Tobacco and E-Cigarette Products (Miscellaneous) Amendment Bill 2024 was introduced by independent Hon. Frank Pangallo and passed through the upper house of the state Legislative Council, the first step towards being fully legislated. It includes a TFG element that precludes the sale and supply of tobacco products to people born on or after 1 January 2007 and faced no opposition by the major parties.In November, Members of Parliament in the UK voted in favour of the Tobacco and Vapes bill (415 votes for, 47 votes against), which will make it an offence to sell tobacco products, herbal smoking products and cigarette papers to anyone born on or after 1 January 2009. The next steps are that the bill passes through a Committee Stage, whereby MP committee members examine the bill and propose and debate amendments.Finally, it was recently reported that four states in India have initiated TFG policies. In India, Ministry of Health and Family Welfare can consider a national policy when over 50% of states enact a TFG policy.Surgeon general’s report: eliminating tobacco-related disease and death: addressing disparities2024 marked 60 years since the publication of the landmark report from the Surgeon General’s Advisory Committee on Smoking and Health recognising the harmful health impacts of smoking tobacco. Since then, cigarette smoking among adults in the USA has declined from 70% to 11.5% in 2021; a testament to the tremendous impact of tobacco control policies. However, the most recent Surgeon General’ s report released in November 2024 highlighted persistent inequities in commercial tobacco product use, exposure to secondhand tobacco smoke and exposure to marketing of tobacco products. The consequences of these policy-related inequities are seen in greater smoking-related health outcomes among minoritised racial and ethnic groups and sexual orientation and gender identity groups; persons with lower incomes; persons with lower educational attainment; certain occupational groups; persons with mental health conditions or substance use disorders; and persons who live in rural areas or specific geographic regions.The 2024 report is the first to consistently use person-first language, for example, person who smokes, rather than smoker and attempted to identify diverse groups while not perpetuating ‘minoritisation’ of populations, recognising that race, ethnicity and minoritisation are social constructs and that terminology referring to groups who have been marginalised is expected to change over time as these groups and group members identify appropriate and acceptable labels and language.Examples of inequities highlighted in the report include how smoking prevalence is highest among American Indian and Alaska Native people, and is increasing among American Indian and Alaska Native youth, even though smoking among young people overall is declining. Black people are disproportionately exposed to secondhand smoke compared with people in other racial and ethnic groups and children are disproportionately exposed to secondhand smoke compared with adults. There is a widening of disparities in smoking by educational attainment, and higher prevalence among people living in poverty compared with people living at or above the poverty line. Smoking prevalence is also highest among manual labour workers, service workers and mining workers and people who identify as gay, lesbian and bisexual. Tobacco use is higher in the South and Midwest and among people living with any mental health condition or substance use disorder.Policies that restrict menthol and other additives can provide opportunities to decrease smoking-related harms as menthol and sweeteners can increase smoking uptake. Some natural and synthetic chemicals and flavourants can act as cues and reinforcers, and natural and synthetic coolants, even those without a taste or odour can increase the appeal and use of tobacco products. Marketing of menthol products in particular, is more prevalent in higher proportions of black people, Hispanic people and residents with lower incomes.There are multiple other examples of the tobacco industry targeting groups with marketing and advertising of tobacco products, including using influencer marketing, as well as cheaper products in communities with diverse racial and ethnic populations, and discount coupons provided to the LGBTQI+ community and people with lower socioeconomic status. The tobacco industry also continues to try to rehabilitate its image, employing political, legal, economic, corporate social responsibility and community tactics among its target communities.The report also outlined the disparities in disease outcomes and mortality attributable to tobacco use. The overall prevalence of chronic obstructive pulmonary disease (COPD) is highest among American Indian and Alaska Native adults and there is a clear socioeconomic gradient for COPD prevalence and mortality, with higher prevalence and mortality occurring among people in low-income groups and with lower educational attainment.Importantly, the report also named many opportunities to address tobacco-related health disparities. This includes comprehensive smoke-free laws and prohibiting the sale of flavoured tobacco products and menthol cigarettes, which can reduce tobacco use and increase smoking cessation. Regulation of the location and number of tobacco retailers in neighbourhoods with a high proportion of lower-income, Black or Hispanic people could reduce retailer density as well as exposure to tobacco advertising and marketing and increases in tobacco product prices will reduce tobacco use to a greater extent among people of lower socioeconomic status and other groups who are price sensitive such as youth. Mass media counter-marketing campaigns can increase quit attempts among many population groups particularly when designed and delivered appropriately. This, in turn, requires increased access to cessation support for people in these groups and cultural tailoring of cessation interventions. Other promising evidence-based interventions include reducing nicotine in cigarettes and other combustible tobacco products to minimally addictive or non-addictive levels.In closing his preface to the report, the Surgeon General, Vice Admiral Vivek H. Murthy urges “a whole-of-society effort to reach the tobacco endgame: a world in which zero lives are harmed by or lost to tobacco use.”China: cigarette card game among Chinese youth: a new challenge for tobacco controlChina is the largest tobacco producer and consumer in the world, despite significant recent progress in tobacco control. Smoking is still deeply ingrained in Chinese culture, often associated with social interaction. Recently, a troubling trend among primary school students has emerged and been widely reported online: the cigarette card game, which involves collecting and trading cards made from discarded cigarette packages.Cigarette cards are made by folding the lids of empty cigarette packages into square shapes (figure 1), which are then used as toys. Cards are placed on the ground and flipped alternately; whoever flips the opponent’s cigarette card wins it. Recently, this game became popular among primary school students and was widely reported by the Chinese online media. According to online reports, cards are ranked based on cigarette brands, with higher-priced brands considered more valuable and thus ranked higher. Children are drawn to these cards for their colourful designs and the excitement of the competition. They typically acquire cigarette cards by collecting used packs from family members, scavenging from trash or using portions of their allowances to build their collections. Some even urge family members to contribute more empty packs.Figure 1Cigarette card reported in online news or reports in social media.Youth access to cigarette cardsCigarette cards are easily accessible to children. On Taobao, China’s largest online shopping platform, searching ‘cigarette card’ results in over 6000 listings, with the highest-selling items having over 20 000 orders (figure 3). These cards are priced between 3 and 100 yuan per set of 10 (approximately US$0.42 to US$14.00) and are marked with catchy slogans such as ‘direct supply, see who has more’ and ‘high chance of rare cards, no need for mom to worry about me picking up cigarette packs anymore’. These cards are also sold in ‘cultural goods stores’ online, which do not require age verification. There are also reports that children can buy these cards from small shops near schools.Figure 3Cigarette cards sold on online shopping platforms.Tobacco promotion has been related to positive attitudes, beliefs and expectations regarding tobacco and increases the likelihood of initiation. These games indirectly promote tobacco by familiarising children with brands and imagery, potentially normalising smoking and reducing perceived risks and promoting early initiation through the ‘mere exposure’ effect.Cigarette card games also satisfy children’s need for peer acceptance and enhance their popularity through the collection of ‘rare’ cards. Additionally, the game can evolve beyond simple collecting to include gambling behaviours, where losers must surrender cigarette cards or even money to winners. In some cases, trading cigarette cards among children has escalated from mere game play to actual gambling, enhancing the stakes and risks involved.Regulatory and cultural challengesThe emergence of the cigarette card game underscores significant regulatory loopholes in tobacco marketing to children. Although the Chinese government has made efforts to prohibit cigarette advertising and curb illegal sales to minors, these measures are inadequate in addressing tobacco packaging exposure. Insufficient social media regulations further allow the spread of tobacco-related content mean that children still have easy access to inappropriate content. The effectiveness of content regulation is undermined by the platforms’ reliance on self-regulation.These loopholes are amplified by poorly regulated package warnings and cigarette promotions that incorporate Chinese cultural elements, such as representations of Chinese plants, animals and apparel/beauty. The WHO recommends all countries introduce plain tobacco packaging, which standardises all elements of the tobacco pack and removes colourful branding and imagery. The most recent 2015 packaging regulation mandated three-line health warnings to cover 35 % of the bottom surface of cigarette pack, but in practice, warnings only cover about 15 % of the package, allowing visually appealing branding to remain dominant.In response to the cigarette card game, various regions in China have implemented targeted measures. For instance, in Meilan District, Haikou city, authorities launched a month-long campaign enforcing strict inspections and banning the game in schools and nearby areas. Gaozhou’s Dajing Town initiated a safety campaign against the illegal sales of cigarette cards around schools, involving multiple government departments. However, these efforts reflect a fragmented approach to enforcement.The popularity of cigarette cards among primary school students calls for enhanced surveillance and early preventive measures to avoid jeopardising China’s ‘Healthy China 2030’ goal of reducing smoking rates to below 20%.Tianqi Chen, School of Public Health, Peking University, People’s Republic of China, Other contributors to this article include: Grace Kong, Department of Psychiatry, Yale School of Medicine, USA; Bingliang Lin, Shenzhen Center for Chronic Disease Control, No. 2021 Buxin Road, Luohu Distinct Shenzhen 518001, People’s Republic of China; Wenlong Lu, Shenzhen Center for Chronic Disease Control, No. 2021 Buxin Road, Luohu Distinct Shenzhen 518001, People’s Republic of China; Jingfan Xiong, Shenzhen Center for Chronic Disease Control, No. 2021 Buxin Road, Luohu Distinct Shenzhen 518001, People’s Republic of China.Ethics statementsPatient consent for publicationNot applicable.Ethics approvalNot applicable. 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