International Consultation on Tobacco and Youth - What in the World Works?
Dr Derek Yach, Executive Director
Noncommunicable Diseases and Mental Health, World Health Organization
Singapore, 28 to 30 September 1999
Opening Address
It is a privilege to welcome you to this International Consultation on Tobacco and Youth. One year ago, Judith Mackay and I were in Singapore discussing how to move ahead in the important area of youth and tobacco. It is a tribute to the enthusiasm, leadership and interest of people in Singapore, particularly the local organizers at the Singapore Ministry of Health and the Singapore Cancer Society, that we are here today to consider "What in the World Works" to protect children and youth from tobacco. Good question. In fact the more we know, the more there is to know.
Most of you know the basic facts about tobacco : there are 4 million deaths from tobacco every year. This figure will increase to about 10 million by 2030 by which time 70 percent of the deaths will occur in developing countries. For the tobacco industry to survive, these deaths and the millions of adults who quit, must be made replaced by new smokers: the children and youth of today and tomorrow. In ever-increasing numbers, this is happening among youth in countries like China, India, Egypt and Thailand. We know that cost-effective policies and interventions exist to reduce tobacco consumption - what is needed is political will and concerted action.
Under the leadership of the Director-General of WHO, Dr Gro Harlem Brundtland, the Tobacco Free Initiative was established to raise the profile of tobacco as a serious global threat to public health. It has worked hard to build strong partnerships within the UN, especially with UNICEF and the World Bank, to address tobacco use. Even more importantly, new country actions against tobacco are being reported weekly; NGOs from a wide variety of development sectors are taking up this issue as a major concern, and the private sector has been a strong supporter of the renewed WHO approach.
Tobacco is a unique threat to health because it is so widely available, it kills when used as intended and those who manufacture and market tobacco have systematically worked to undermine efforts to curb the carnage and death toll from tobacco.
In that context, protecting youth from tobacco is doubly important. Roughly 90% of adult smokers were established smokers before the age of 18 years, meaning that prevention of youth smoking translates into prevention of adult smoking and its adverse health effects. In addition, adults who are very heavy smokers are more likely to have begun at younger ages than adults who smoke less, meaning that any success at postponing the age of smoking translates into potentially less health burden, even for those who become addicted to nicotine and smoke through adulthood.
Despite the obvious benefits of preventing smoking, young people in many countries have high and growing rates of smoking. Part of the explanation lies with efforts by the tobacco industry: efforts that are well described in documents that have come to light as a result of tobacco litigation. I will return to this point.
We need to draw on existing resources and skills but also on new evidence, new tools, and new insights. A big advantage of efforts to protect youth from tobacco is the incredible energy and resourcefulness of people who work with young people, whether as teachers or through youth clubs and youth activities. Our challenge is to build more effective partnerships to ensure that we are implementing policies and programmes strongly rooted in evidence and in community structures. Ineffective programmes waste scarce resources. Programmes poorly supported by communities are not sustainable.
The UN Foundation, recognising the pivotal importance of improving the evidence base for youth & tobacco activities, has funded a joint WHO/UNICEF project to strengthen that evidence base. IDRC Canada's Research for International Tobacco Control and CDC Atlanta have also joined forces under the banner of the UNF project to spearhead a broad-based approach to tobacco control among youth. Later this morning, you will hear from investigators in Phase 1 of that project who have demonstrated beyond doubt that tobacco's ill effects are affecting children in countries all over the globe.
In each region, the UNF Project has enabled researchers to critically review the evidence from the countries in their region and their results are alarmingly repetitive. Just two examples should help galvanise our discussions here - first, children are smoking more and starting smoking at younger ages, and second, women who smoke during pregnancy have smaller birth weight babies, babies at higher risk of dying or being sick as infants. That holds among women in rural and urban areas, developed and developing countries. In fact in virtually every one of the dozens of settings where the question has been asked, the answer is the same - smoking during pregnancy reduces birthweight, increasing risks of adverse outcomes for both mother and child.
More evidence comes from the Global Youth Tobacco Survey, GYTS, implemented in partnership with CDC in 11 countries with more planned in the coming years. During the next few days, we will hear the first results from the school-based surveys that, in many countries for the first time, provide accurate measures of how many young people smoke and young people's attitudes and knowledge regarding tobacco products and the harms they cause. The GYTS will also be a powerful tool, to measure change in the ultimate outcomes in tobacco control, namely reduced tobacco consumption.
Another important tool comes from work with our UNICEF partners in the UNF Project, the potential power of the Convention on the Rights of the Child. This international human rights treaty has been ratified by all but two countries. Work is ongoing to unleash its power to monitor the tobacco epidemic as it affects young people and to use the CRC provisions to call upon national governments to take effective steps to implement comprehensive tobacco control measures. By linking work on the Convention on the Rights of the Child to tobacco control, a broader constituency of advocates for action will be developed.
There are other settings where the damage is probably worse and where our knowledge base needs to expand to. I am talking of those millions of children especially in developing countries who do not go to school but who are victims of tobacco. It is on them that the double burden of disease - poverty and ill health - falls. The tobacco industry does not discriminate between the rich and poor - for them we are all potential consumers.
Let me turn now to the tobacco industry. Protecting children and youth from tobacco is a battle with a well-financed and supremely well-organised adversary. For decades the industry has honed its strategy to influence the policies of governments, UN agencies (including WHO) and research bodies. Understanding industry behaviour is essential if we are to have any effect in the face of hundreds of millions of dollars of industry resources directed at marketing and promoting tobacco products. No one working in malaria would consider developing policies and interventions without understanding the structure, functioning and best means to reduce the impact of mosquitoes: the vector of malaria. Yet for decades, tobacco control policy makers have not had much insight into our vector: the tobacco industry. Increasingly we do, and I would urge participants to explore the several websites available that contains tobacco industry records from the far and recent past.
The mountains of documents that have become available from litigation provide plenty of reasons to be concerned about the tobacco industry. This information is now the basis of the latest USA federal lawsuit filed last week against tobacco manufacturers. Among the 35 million pages of memos and plans have been extensive studies of attitudes of children towards tobacco and smoking and various projects that sought to establish brand recognition among underage smokers. Judith Mackay will review some of the latest revelations to come out of the documents.
One of the most comprehensive reviews of tobacco industry actions in relation to underage youth smoking was released only 10 days ago in the Archives of Paediatric and Adolescent Medicine. The author, Cheryl Perry, presents extensive evidence that tobacco industry actions were a substantial factor in increasing underage youth smoking. One success of their efforts in the United States was reported in the Journal of the American Medical Association: recognition of Joe Camel, a cartoon character developed to promote Camel cigarettes, was reported to be over 90%, higher than that for Mickey Mouse!
In a major study by Philip Morris of "smoking habits of young smokers" in the USA, brand preferences were related to sex, age and race. The concern of Philip Morris was that certain groups, particularly 15 to 18 year olds, were not attracted to their brand. The researchers commented that " we are not sure that anything can be done to halt a major exodus if one gets going among the young. This group follows the crowd ... they will follow the leader ... jump on the bandwagon."
But what would happen if the leader did not smoke? And if the crowd does not smoke? Then the needed new recruits fade away fast. That is the view of the largest tobacco multinational: we need to make it a reality!
Before coming to Singapore I had a look at what was available on just the Philip Morris website. I found nearly 1000 documents that referred to Singapore. Many contained information about strategic marketing plans extending back decades; and about the growing frustration of the tobacco industry towards the successful control measures introduced by the Singapore government over several decades. But there were also worrying examples of attempts to develop new products aimed at young people. One document from 1987 describes the proposed product launch of CALIFORNIA in Singapore. Two product types were tested in "very young smokers": a cigarette with an added sweetener and another with an aroma scented tear tape. The fact that it was tested in "very young smokers" probably means that they were the intended target audience! These and other findings should stimulate outrage among youth leaders and policy makers: outrage that needs to be turned into focussed, strategic policy to stop children ever starting and supporting youth who smoke to quit.
Over the next three days, we will have ample opportunity to review the tactics used by the tobacco industry, but I want to pose these points for reflection:
First, the industry is not stupid and has studied young people in order to understand how to sell them something, moreover a something that in initial use makes most people cough and splutter and often feel nauseated. If we are concerned about young people and tobacco, we need to work far harder to understand young people rather than simply presuming that, as adults, our interest in protecting children frees us from listening to them and working with them. During this conference, we will hear about strategies addressing tobacco and youth that not only target youth, but also actively involve them in conceiving and implementing programmes. The tobacco industry successfully did this to build a global market - we need to do so to build a tobacco free world. And we will do this with the children and the youth of the world.
Second, we must not be led into thinking that tobacco control and youth is just about educating young people - effective interventions that comprise comprehensive tobacco control, particularly those related to increasing prices, banning advertising and creating smoke-free public places are essential in preventing smoking among young people. If we limit our attention to school or community education efforts, and reducing youth access, we will commit two grave errors: first, we will have failed to use the most effective tools in the battle for a tobacco-free generation, and second, we would have walked into a trap laid by the tobacco industry.
The best-resourced efforts to develop programmes to prevent young people smoking are those led by the tobacco industry itself. In the US State of West Virginia alone, the state has been offered 4.5 million American dollars to implement an industry-developed campaign to prevent youth smoking. Philip Morris and BAT are actively trying to induce governments from Switzerland to Zimbabwe to take their money and their methods to protect children from tobacco. None of the industry programmes includes steep tax increases or total bans on advertising and promotions or quitting programmes. We must not limit our discussions at this meeting about what works in reducing tobacco use among young people to education campaigns!
Third, some of you may ask what is so bad about accepting these programmes, particularly in resource-strapped environments where the apparent generosity of the industry translates into art programmes for children or school health programs where previously there were none? Our response needs to be clear-headed and rooted in evidence. If we all learned as children that the fox cannot be trusted to guard the chickens, are we as adults suddenly going to entrust the future health of our children to programmes developed by an industry that seeks to sell those same children cigarettes?
In concluding her article on the tobacco industry and underage youth smoking, Cheryl Perry urged that "tobacco industry promises and actions ...should be closely scrutinised and monitored because the industry's survival depends on underage replacement smokers". Based upon factual evidence tobacco industry actions "may continue to contradict their promises". The bottom line: as educators proclaim to youth "resist the cigarettes", potential recipients of tobacco industry money need to resist the offer for the sake of child health!
This meeting on Tobacco & Youth: What in the World Works is a critical step towards defining best practices to guide programming aimed at children and young people. Before we can legitimately fault the industry-developed programmes, we need consensus on what works in tobacco policies and programming to reduce tobacco use among young people. This means subjecting many of the current policies and programmes to rigorous evaluation - because we have schools and health education does not mean that school-based health education will automatically be the centrepiece of effective efforts to reduce youth tobacco use. What it does mean is that we must develop policies and programmes that interact with young people's lives at home, at school, at play, at work, with peers and with adults, creating an environment from which a generation of tobacco free youth will emerge.
As a final thought, I want to impress upon you the need for broad thinking if we are to answer the question inviting us all to this meeting: Tobacco & Youth: What in the World Works? If we expect young people to resist tobacco use, it is essential that we provide governments with meaningful, effective alternatives to becoming accessories to tobacco promotion through their acceptance of industry-developed campaigns.
We need to find ways to unleash the creative talents of youth groups against the attempts of the tobacco industry to continue to dupe them into believing that tobacco is cool, the right thing to do and the way to be part of the in-crowd. Remember it was Philip Morris researchers who expressed concern about the power and unstoppability of the crowd when it deserts their brand. Let's think about how this can be made a reality for all tobacco brands. To do so we will need to follow Dr Brundtland's advise when she addressed the International Policy Conference on youth and tobacco in Washington in March this year. She reminded us that "our main battleground is adolescence. We must enter the discotheques, the schools, the sports arenas: In many countries, cigarettes are given out free on the dance floors. We have to win these spaces back."
For the first time in WHO's history, its Member States are exercising their mandate to develop a convention. Next month, the intergovernmental process, leading to the negotiation and adoption of the Framework Convention on Tobacco Control, will commence. Like polio eradication, the Framework Convention will forge global solidarity to address a shared public health issue of concern to children around the world. This major step by WHO and its Member States takes a long-term view to public health development; the implementation of the Framework Convention on Tobacco Control will make the world a safer place for the children of the 21st century.
As adults, as advocates for children and as advocates for tobacco control, we have come from around the globe to this meeting in Singapore - the time has never been better to make real progress towards identifying What in the World Works.
Thank you.