¿Por qué nosotros no? Acción Ciudadana por la Salud y el cambio de la Ley Española de Tabaco

... meeting of the Council of the National Health System, the Minister of Health announced a smoking ban in outdoor public places if a 2 meter distance is not possible.

The significant impact of COVID-19 and new outbreaks in several regions of the country after the 100-day lockdown (between March 15 and June 21) partly explain this measure aimed at curbing the resurgent disease. Previous campaigns from both non-governmental organizations (NGOs) and scientific societies, together with a favourable anti-smoking social climate, also triggered its adoption.

In May, the Spanish Government made the use of face masks compulsory in streets and other outdoor spaces, and in all public indoor places where physical distancing of at least 1.5 meters is not possible. This requirement expanded the requirement to wear masks for all transport and workplaces, which had already been passed as part of the lockdown. Early in June 2020, the NGO “Nofumadores.org” launched the campaign “Smoke-free terraces, right now!” through the platform change.org which has collected almost 89,000 signatures to date.

At the same time, the working group on tobacco control of the Spanish Society of Epidemiology wrote a fact sheet and launched a press release pointing out the higher risk of SARS-Cov-2 transmission due to smoking in outdoor public places, mainly because of the emission of droplets and their diffusion with smoke or other aerosols (in addition to the hand-mouth movements and manipulation of face masks, and the risk of relaxing of distancing). Following this policy brief recommendation, and statements from other scientific societies and professional associations (national committee on smoking prevention, society of public health, society of respiratory medicine, and the federation of physicians’ colleges) in early July the Ministry of Health recommended avoiding tobacco consumption in community and social settings. On July 30, the NGO “Nofumadores.org”, with 20 scientific societies, consumers organizations and health professional associations, including the European Network for Smoking and Tobacco Prevention and ASH United States, sent a manifesto to the Minister of Health requesting the urgent prohibition of smoking on terraces of hospitality premises, and all outdoor public places. These requests have been widely covered by the media and social networks.

Whilst public health and tobacco control stakeholders welcome this step forward, a real and permanent ban of smoking in terraces and outdoor spaces has not been passed. The agreement of the Council of the National Health System on tobacco or other tobacco or similar products use states that smoking in the streets or in outdoor spaces is forbidden when a minimum 2 meter distance could not be achieved. Hence, smokers are allowed to remove their face mask while smoking in outdoor places whereas non-smoking people have to wear it, since the use of masks is mandatory in public places.

The Spanish regulation of smoking in outdoor spaces is consistent with the WHO statement on tobacco use and COVID-19, the risk for inhalation exposure to coronaviruses in microscopic respiratory droplets that could likely be enhanced by smoke and aerosols exhaled by smokers or users of other electronic devices, and that outdoor smoking bans have good acceptance and support by the population. Governments in other jurisdictions should take note of the Spanish experience to contribute to curbing the COVID-19 epidemic, prevent new outbreaks and potential new waves.

Esteve Fernández, Cristina Martínez are with the WHO Collaborating Center for Tobacco Control, Catalan Institute of Oncology; Tobacco Control Research Unit, Bellvitge Biomedical Research Institute; School of Medicine and Health Sciences, University of Barcelona; CIBER Respiratory Diseases.

... same.

But it warns of the danger of stalling efforts to eradicate nicotine addiction and its associated risks, especially in the most disadvantaged households.

"They are ahead of us," commented the president of the European Network for the Prevention of Smoking, Francisco Rodriguez-Lozano.

He pointed out that the Spanish law of 2010 was a pioneer but that currently there are EU countries such as France, the United Kingdom, Belgium, Slovenia or Romania that have approved more ambitious measures, such as forcing the packs of cigarettes to be "neutral" and not show the brand.

And among the complementary initiatives proposed by this "road map" to contain smoking, the attention to new products such as electronic cigarettes or vaporizers stands out, an upward phenomenon that they want to avoid being "normalized".

Young people "do not have smoke-filled discos in their retina", but those devices that sell tobacco to replace the fall of sales of traditional cigarettes are "flooding the classroom" in the United States, warned the president of the National Committee for the Prevention of Smoking, Regina Dalmau.

"We have to regulate it before it is a new problem," added the cardiologist in a debate that included representatives of civil society, medical associations, the Ministry of Health, the Spanish Representation to the EU, MEPs and Spanish national deputies.

In this sense, they ask that the taxation of all products containing nicotine be equated to the increase, while pointing out that a significant increase in the price of cigarettes favors the reduction of their consumption.

The professor of Pharmacology at the University of Cantabria Javier Ayesta explained that the rise should be "a minimum 20%" for its effect to be noticed, and cited as an example France, where there are a million fewer smokers since the pack was It sells with standard package and at a price of 8 euros whereas in Spain it does not reach 5 euros.

Other measures promoted by the Madrid Declaration include requiring compliance with current legislation regarding closed or semi-enclosed public spaces, prohibiting smoking in any type of vehicle, promoting smoke-free homes, facilitating and financing access to professionals and treatments. health and extend the regulations on tobacco and advertising to new products.

"It is the first public health problem in Spain due to mortality," said Araceli Arce, general deputy director of Health Promotion of the Ministry of Health.

In spite of progress having been made, tobacco consumption is still a problem in Spain and one which requires appropriate measures to be taken

Tobacco consumption is responsible every year in Spain for the death of more than 50,000 people, people who for the most part began to smoke long before reaching the age of majority. As the first cause of preventable death in our country, it represents an obstacle to the right to health and life of Spaniards, a right recognized in numerous human rights treaties ratified by the Spanish Government, among others the Convention on the Rights of the Child, the Convention on the Elimination of All Forms of iscrimination Against Women and the International Covenant on Economic, Social and Cultural Rights, which in Article 12 states that countries must respect and protect “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”.

The coming into force in 2005 and 2010 of two Spanish laws on smoking-related health measures contributed to a progressive denormalization of its consumption and resulted in a notable improvement in the health of the Spanish population.

The two primary effects of these laws were the decrease in the general exposure of the population to environmental tobacco smoke and the disappearance of direct and indirect advertising of tobacco products. This contributed decisively to an increase in the perception of risk associated with tobacco consumption in the general population. In the last decade, the percentage of

smokers has decreased significantly which is due to the fact that many smokers multiplied their cessation attempts and that a lower percentage of adolescents has taken up smoking.

The achievements of these two laws are evident but this should not make us lose sight of the original limitations of these regulations nor the aspects pending implementation. Today we can observe that:

- there continue to be spaces where part of the population is exposed to environmental tobacco smoke;

- one in four people still smoke, a figure significantly lower than in 2004, but one

excessively high for a risk factor that causes the premature death of half of its

regular consumers;.

- tobacco consumption is highly prevalent in people belonging to the most

disadvantaged social levels, something that is seen both in the adult population as

well as in the infant-juvenile population, and which is especially striking in the

case of pregnant women

- the Spanish public health system – exemplary in so many aspects – does not

always offer people suffering from this addictive disorder the effective diagnostic

and therapeutic possibilities available In a somewhat paradoxical manner, the evident improvements attained in recent

years have contributed to a situation where some regulators have the perception that almost everything has already been done regarding tobacco and that now it is time to focus on other public health problems. Nevertheless, without meaning to underes-

timate any other health problem, whose clinical and community approach can be improved, scientific evidence unequivocally shows that:

- tobacco consumption is still the main public health problem in our country, due to

the morbidity and mortality it generates as well as the reduction it causes in

quality of life and life expectancy;

- there are effective tobacco control measures that have been carried out in other

countries which have not yet been applied in Spain or that have been carried out

in a partial or deficient manner.

The signatory organizations of this document – scientific, health and social, all of them advocating for tobacco control in Spain – are concerned about not being able to offer our population the evidence-based strategies that have been shown to reduce tobacco harm as well as not being able to provide them with adequate tools to face up to the direct and indirect pressures coming from transnational tobacco industries to take up and keep up tobacco consumption. We are concerned about failing in particular those people who belong to the most disadvantaged segments of the population, in which a relative lack of various social, psycho-affective or economic resources means that they have more problems in dealing adequately with this disorder and that their prevalence of consumption is much higher than the rest of the population. This higher prevalence is a factor that contributes - and will continue contributing - to increasing social inequalities in health.

For all these reasons we consider it urgent that a series of measures be taken in our country and that we return to acquiring the social leadership we achieved in Europe in this field in the first years of this century. According to the scientific evidence available, these are the main measures that the public authorities should adopt in Spain:

1) related to article 6 of the World Health Organization Framework Convention on

Tobacco Control 2003 (FCTC):

- harmonise upwards taxation of all tobacco products;

- also harmonise taxation of products related to nicotine delivery and novel

tobacco products;

- increase the fiscal pressure on all tobacco products, bringing them into line

with most developed countries, in order to reduce their accessibility to the most

vulnerable populations, above all minors;

2) related to Article 8 of the FCTC:

- demand compliance with current legislation on consumption in enclosed or

semi-open public places (such as terraces, patios or transit areas in shopping

centers);

- apply the current regulation on smoke-free spaces to all related products

(electronic cigarettes and herbal products for smoking). All this with the double

objective of, on the one hand, avoiding the passive toxicity that these products

can cause, and on the other hand, achieving denormalization of their con-

sumption in public places;

- prohibit smoking in any type of vehicle to avoid smoke exposure for all

passengers, especially minors, for reasons of health and road safety;

- Extend the current legislation in accordance with the normative recommen-

dations and guidelines of the World Health Organization on the protection of

environmental tobacco smoke by means of: 1) the elimination of ambiguities

(definition and delimitation of outdoor spaces, exceptions in enclosed spaces,

etc.); 2) the expansion of smoke-free environments in some open air spaces

(sports and entertainment facilities, platforms and stops for means of transport,

beaches and other natural spaces, communal swimming pools); and 3) the

explicit involvement of the different security forces involved in the control of

enforcement of the Law;

- promote smoke-free homes and raise awareness among the general

population regarding passive smoking, as the home is currently the main place

of exposure to environmental tobacco smoke, responsible for morbidity and

mortality in adults and children

3) related to Article 11 of the FCTC:

- introduce plain packaging, as several countries have done, in order to reduce

the attractiveness of the product to minors and increase the perception of risk;

4) related to Article 12 of the FCTC:

- Carry out targeted campaigns on diverse segments of the population that

allow them to acquire an adequate perception of risk regarding tobacco con-

sumption. In this regard, campaigns such as the ‘Every cigarette is doing you

damage’ one are recommended, an initiative that has proven its effectiveness

in multiple countries of varying characteristics;

5) related to article 14 of the FCTC:

- facilitate access of the smoking population to health professionals trained in

the approach to tackling tobacco consumption and in the treatment of smoking;

- finance those clinical, behavioral and pharmacological interventions which

have demonstrated effectiveness and safety in smoking treatment;

6) related to other FCTC articles:

- reinforce and harmonise the regulation on advertising, promotion and spon-

sorship of tobacco products to related products, in addition including devices

used for their consumption (such as pipes, water pipes, HNBs, etc.) (Article 13

FCTC);

- eliminate advertising of tobacco and related products at points of sale (Article

13 FCTC);

- reinforce the ban on sales to minors, also addressing issues related to toba-

cco or nicotine delivery products distributed on the internet (Article 16 FCTC).

This set of measures is not intended to be exhaustive.

Scientific evidence from various countries (who have already applied such measures)

shows that their application will contribute decisively to ensuring that those who do

not want to start consumption do not do so and that those who want to quit have

more chances of quitting.

Most of these measures can be applied with hardly any cost, and some of them imply

a highly cost-effective investment when compared with other health measures that

our health system has adopted and considers irrevocable.

We ask the public authorities to prioritize the right to health and act. Smoking

remains the main public health problem in our country, a problem that is avoidable

and directly affects a quarter of the adult population. There is an urgent need for

public authorities to establish an action plan or roadmap with the aim of reducing

tobacco consumption in Spain.

To do so they can count on all our social as well as professional support.

Madrid 16th June 2018

... directive, which tobacco control experts consider a victory for the tobacco industry.

Van Woerden, using freedom of information requests, had to struggle to get the reports from these meetings released. His article shows clearly that the Commission’ tax department ignores the obligations outlined in the UN’s tobacco control treaty to avoid tobacco industry influence by reducing contacts to a minimum and securing full transparency around such contacts.

In December European Ombudsman Emily O’Reilly had highlighted the Commission's general failure to meet its obligation under Article 5(3) of the UN tobacco treaty. In a 2016 ruling, the Ombudsman found the Commission guilty of maladministration and asked the Commission for a “pro-active transparency policy regarding meetings with tobacco lobbyists”, across all Commission services and staff. The Commission, however, stubbornly refuses to follow the Ombudsman’s recommendations, despite both the European Parliament and health Commissioner Andrukaitis agreeing with the Ombudsman.

In January, the World Health Organisation published a report on “good country practices in the implementation of WHO FCTC Article 5.3 and its guidelines”. The report praises the EU only once, when it mentions the European Ombudsman’s office which has its own measures to implement the UN rules. The good practice report does not mention the European Commission at all.

The WHO report concludes that protecting health policy from the vested commercial interests of the tobacco industry “is best done when protective measures are applied government-wide”. “This government-wide approach”, the report states, “stops the industry from utilizing non-health departments to represent its interest to undermine or weaken tobacco control”. This government-wide approach is exactly what the European Commission is refusing to introduce (only the Commission’s health department is pro-actively disclosing meetings with the tobacco industry).

To encourage a different approach, CEO has earlier this month (jointly with the Smokefree Partnership) submitted a freedom of information request to Commission President Juncker, asking for the release of all reports (and other notes) from meetings and all correspondence with the tobacco industry. The Commission has to respond before the end of February.

The least the Commission could do is to follow the example of the Dutch government, which since 2016 has a central portal where it publishes all meetings with the tobacco industry (across the government and its departments). The Dutch government clearly spells out that the objective is to protect public health policies from tobacco industry influence. It states that contacts with the tobacco industry should be limited merely to implementation matters.

The enforcement is far from perfect, as the Dutch TabakNee website points out, but the comparison with the Dutch governments efforts to implement the UN tobacco treaty shows just how irresponsibly the Commission behaves on these matters. Unless things change in the coming months, Commission President Juncker risks leaving the Commission in 2019 with a legacy of far-reaching complacency about tobacco lobbying influence.

... while continuing to promote sales of its top-branded Marlboro cigarettes and oppose policies that would genuinely reduce their use, clearly believes this investment will further its “harm reduction” agenda, led by its new heat-not-burn product, IQOS. But don’t worry, the Foundation assures everyone that “PMI and the tobacco industry are precluded from having any influence over how the Foundation spends its funds or focuses its activities.”

Except that is what a broad range of industry front groups, sometimes headed by respected and even well-intentioned leaders, have been saying since the “Frank Statement” of 1954. The long and sordid history of the industry’s funding of “research,” a major part of the mission of this new foundation, is replete with exactly this sort of blithe reassurance, as Yach himself pointed out in an earlier time. In reality, nothing has changed. The “research” really isn’t the point anyway. The mere fact of having landed Yach is a major public relations coup for PMI that will be used to do more of what the industry always does: create doubt, contribute further to existing disputes within the global tobacco control movement, shore up its own competitive position, and go on pushing its cigarettes as long as it possibly can.

In the video, Yach invites “everyone” to join the “movement” this new organization is starting – implicitly dismissing the past 40 years of tobacco control activism and advocacy and 60 years of tobacco industry lies and duplicity. Leaders of active existing civil society coalitions like the Framework Convention Alliance and the Noncommunicable Disease Alliance were blindsided. Contrary to the video’s claim, there is no shortage of “fresh thinking” in the already-vibrant, already-existing global movement to end the tobacco epidemic. There are many great “endgame”-furthering ideas now being actively debated, studied, and tried out: the primary obstacle to implementing them is the tobacco industry.

PMI hasn’t stopped opposing the policies that would reduce tobacco use, has it? No: recently leaked documents show that PMI continues to actively oppose any policy that could genuinely reduce tobacco use. Countries around the world identify the tobacco industry as the single biggest barrier to progress in implementing such tobacco control policies. This “new” initiative is just more of the same lipstick on the industry pig, but in a way it’s far worse this time: by using a formerly high profile WHO leader as a spokesperson, PMI can also accelerate its longstanding ambition to splinter the tobacco control movement.

It’s also not true, as the video suggests, that tobacco control efforts have “plateaued.” Cigarette consumption is declining and since 2003, more than 180 countries have become parties to the World Health Organization Framework Convention on Tobacco Control (FCTC), committing themselves to implement effective policy measures and building public support for ending the epidemic. PMI knows this, hence its ongoing, covert and overt efforts to stymie the FCTC. For example, at the last Conference of the Parties, the meetings where implementation of the treaty is discussed, tobacco farmers organized by PMI demonstrated outside the venue and PMI representatives met secretly with delegates to the meeting.

The company hasn’t announced it is going to stop promoting cigarettes to kids in Africa and Asia, has it? No: in fact, it’s developing “stronger” products for some markets, and continuing to aggressively promote Marlboro cigarettes to the young through campaigns like “Be Marlboro”(see also here and here). Despite decades of developing and then abandoning so-called “reduced harm” products, cigarettes remain PMI’s biggest moneymaker, dwarfing anything else. Only the profoundly naïve will believe that PMI is not solely promoting its self-interest in supporting this new “foundation”.

In fact, the announcement came the day after a huge win for tobacco control: the exclusion of tobacco companies (as well as makers of cluster bombs and some other unsavory actors) from membership in the United Nations Global Compact, due to their incompatibility with responsible business principles. Tobacco control leaders across the globe are convincing governments to protect health policymaking from tobacco industry influence, in line with Article 5.3 of the FCTC. PMI’s response is a new industry sponsored entity, eager to work with governments. From its inception, this organization will constitute a challenge for Article 5.3 implementation.

The timing of the announcement was interesting in another way: just the day before, a new global health initiative led by former US Centers for Disease Control head Tom Frieden was announced, with $225 million in funding from Bloomberg Philanthropies, the Chan Zuckerberg Initiative and the Bill & Melinda Gates Foundation. While this initiative does not focus solely on tobacco, these funders know how much tobacco contributes to disease and death worldwide. They are also funders who have unequivocally taken positions supporting the strong policy measures that work.

What is required to end smoking isn’t helping the world’s leading cigarette manufacturer in its ongoing image makeover while it continues to try to derail the significant public health progress made to date. What is required is leaders who have the humility to work with the movement and policymakers with the backbones of steel needed to stand up to the industry to enact and implement strong tobacco control measures, including high taxes, smokefree laws, effective media campaigns to denormalize both smoking and tobacco companies, and marketing, packaging and retailing regulations to make these deadly products less ubiquitous. The global movement public health activists built over decades of toiling in the trenches must stand together and not allow PMI to buy more time by executing a 21st century version of the “Frank Statement.”

The authors would like to thank Elizabeth Smith and Patricia McDaniel for their input to this article.

... products and forms a key part of Ireland’s strategy to reduce tobacco use, particularly uptake among children and young people,” said Ms Corcoran Kennedy.

The Irish Cancer Society said the legislation was another significant milestone towards the target of a tobacco free Ireland by 2025. Evidence in Australia has shown plain packaging, combined with increases in excise rates, can cut smoking rates, it said.

Pro-tobacco group Forest Ireland described the measure as “gesture politics” and predicted it would not work.