TOBACCO CONTROL: major public health problem—Professor David Simpson, UK

Professor David Simpson of the United Kingdom has been a Visiting Professor at the London School of Hygiene and Tropical Medicine for the past ten years.
 
He has been involved in tobacco control since 1979, running ASH UK, the main UK public health campaign against tobacco, for eleven years, then setting up and running the International Agency on Tobacco and Health to serve colleagues in lower income countries.
 
He wound up its main services (regular information provision and advisory work) in 2007, when most were being taken on by other, much larger international organizations, which crucially also started to fund many local initiatives in target countries.
 
Professor Simpson still lectures regularly to public health Masters Students in several UK universities. Professor Simpson has authored many books on tobacco related issues, viz. Doctors and Tobacco, Tobacco: a Global Threat to Health. He functioned as the news editor of the most prestigious health journal Tobacco Control of the British Medical publications, until recently.
He first visited Sri Lanka in 1981, on behalf of the International Union against Cancer (also known by its French acronym, UICC), and ever since have maintained an interest in the country and its progress in tobacco control policy.
 
Professor Simpson who has been involved in tobacco control (TC) for over 35 years, revealed his experience to share his expertise among global TC activists:
 
* Why tobacco control (TC) is important for a country?
 
Because in almost all countries where there has been widespread tobacco consumption for more than a generation, which means almost all countries in the world, it is the largest preventable cause of disease, disability and premature death.
* How do you describe your contribution towards TC during several decades?
 
For eleven years, as Director of Action on Smoking and Health (ASH) in the UK, I led the campaign against tobacco in the UK, while also gaining insights into the tobacco-related plight of other countries, including Sri Lanka, during brief visits as a volunteer for the International Union against Cancer and the World Health Organization.
 
At the time the UK had a government that had pledged not to take action that would harm the tobacco industry, but luckily it had not taken account the impact of increased tobacco tax when making that pledge. It needed extra tax revenue, in part to fund promised tax cuts that had helped to get it elected, so the one area in which we succeeded in those years was in persuading the government to raise tax, which increased its revenue, but also reduced consumption. In due course, it has led to greatly reduced disease from tobacco, too.
 
* How do you perceive medical professionals’ responsibility, duty and contributions to reduce tobacco consumption?

Probably in every country, and for obvious reasons, doctors are the people whose statements carry the most authority on medical and health issues, so it follows that one of its responsibilities, when considering what it can do about the largest cause of preventable disease, is to work in every way and on every level where it can use such influence.
 
Duty as regards tobacco must be determined by each country’s medical profession after considering all the possible ways of being effective in bringing down consumption and meanwhile treating disease caused by tobacco.
 
The most effective contributions often can turn out be in areas of operation that are not the traditional clinical or research roles. For example, the period in the UK mentioned above, in which the government refused to take significant action aimed at reducing tobacco promotion, or to increase health warnings, was actually a period of almost consistent reduction of consumption. This was because medical leaders - Presidents of the medical royal colleges in the UK (the foremost academic institutions, of physicians, surgeons, etc.) were persuaded to ask the Chancellor of the Exchequer (the UK’s chief finance minister) to raise tobacco tax; and the Chancellor in turn was persuaded to do so, primarily to increase his government’s revenue. In making announcements of each new tax rise, the Chancellor would tell Parliament that the rise followed representations from the medical profession, thereby deflecting criticism away from the Chancellor and other politicians. Since the status on doctors within society was and remains high, there was therefore very little criticism of the rises, except, of course, by those with tobacco industry interests.
 
* Who are the other important stakeholders in promoting tobacco control in a society?
 
It has become clear that effective, lasting tobacco control measures requires agreement, or at least an agreed group of policies, across all departments of government. This is often far from easy to achieve, but it is vital, otherwise the good intentions and work of the health ministry may be undermined by actions of, say, the ministry of finance, or sport.
 
If these other ministries have a fair case for saying that their areas of responsibility will suffer if tobacco control is effective, then the Cabinet must agree to make good the losses, if they are genuine (but the finance ministry will not have a genuine claim – on the contrary, it will be a winner).
 
Looking outside government, news media are probably the most important, not only for general public education, but also for informing politicians and other opinion leaders, about the harm caused by tobacco, and also about what must be done.
 
As many civil society organizations as possible should be involved, too. They can often underpin and increase the demand from the grass roots for proper action, as well as being important players in public education.
 
Within the centre of tobacco control thinking and action, which may be a coalition (of health, consumer and other groups), it is very useful to have at least one economist, or to be able to call on the services of one, and likewise journalists and others who understand how news media work.
 
* How do you see the status of tobacco consumption, industry interference and policy issues in third world countries?
 
This is and will remain for many years one of the most shameful ‘gifts’ of the richer countries, such as the UK and the USA, to other nations, especially low income countries. In total, the unnecessary premature deaths and suffering among the most vulnerable is a disgraceful legacy of so-called ‘development’ in the richer nations.
 
Tobacco industry interference is of course rife in every country where it is allowed to interfere, and adds deception and cynicism to the list of charges that any reasonable human being must necessarily conclude are laid at the door of the big tobacco companies. Policy issues in developing countries carry far more similarities than differences when compared to those in richer countries, even if there may often be large differences of scale. The most obvious differences may be seen or at least thought to exist with regard to countries which grow tobacco. However, thorough economic analysis, such as that published by the World Bank, shows that in almost all tobacco growing countries tobacco is actually a cause of net economic loss, not gain.
 
* How do you justify when a government gives priority to revenue from tobacco industry over people’s health?
 
When this happens nowadays, it must surely be the result of ignorance, misinformation, or lazy or short-term thinking, as good tobacco control policy includes regular tax rises as one of many areas of action. So I cannot see that there can really be any justification, ever, unless we are talking about a very short-term exception such as may be made following a natural disaster, or war.
 
* What specifically do you see in Sri Lanka – progress or regress?
 
Since the first time when I could study tobacco control in Sri Lanka, which was on a visit in 1981, there has, of course, been great progress, not least because so little had been done in those days. While I am less clear about the current situation, as I have not visited lately, nor had so much communication with contacts in the country, I get the impression that momentum has been lost, and that the country has got stuck, so to speak, when so much more can be done. So perhaps there has been some regress, particularly in the strength of will at the top. That may in turn mean that top leaders, who naturally change through retirement or political change, need to be better informed and educated.
 
* Is Pictorial Health Warning (PHW) implementation a result oriented strategy? When cigarettes are bought in loose form, do you think PHW implementation would bring in any results?
 
Yes, it is certainly a strategy that can bear results, and the ‘scream test’ – how loud the tobacco companies scream at this or other policy proposals – bears this out.
 
One goal in every country where cigarettes are sold loose must be to phase out this practice; and even though this is not easy where very poor tobacco consumes live, that does not mean that the goal should be abandoned.
 
Furthermore, PHW must include, eventually, and sooner rather than later, plain packaging, as implemented by Australia, where initial results are looking highly positive.
 
* How do you perceive tax policies towards TC? What are the challenges?
 
The single, really important tax policy most always be to keep raising tobacco tax at least once every year, to ensure that the price paid by consumers always gets more expensive in real terms.
 
* What are the most important strategies to reduce tobacco consumption in a country that should be adopted?
 
Banning tobacco promotion of every type; regular price increases through tax rises; plain packaging with substantial health warnings which change regularly to refresh their effectiveness; a total ban on tobacco use in public places; and an absolute end to letting the tobacco industry, or any other person or organization with an economic interest in tobacco, play any part at all in policy making or review.
 
* What is your idea about the FCTC, its progress? Do you think it has brought in good results so far?
 
In my view, the most important achievement of the FCTC has been to put tobacco control on the agenda of almost every country’s government, at Cabinet or equivalent level. I am unable to comment in detail on its progress, though there are clearly countries that have not ratified it, or lag far behind in implementation. It is to be hoped that progress can be achieved in such backwaters, by whatever pressure WHO or other part of the UN system, or other international players, can exert.
 
* How do you see industry interferences taking place worldwide?
 
Any industry interference is clearly unacceptable. If mosquitoes had a voice, no-one would support their being able to oppose, never mind interfere, with efforts to control malaria.
 
* What are the best methodologies to react to industry interferences, especially CSR?
 
As ever, the best method is a ban, as a thorough enactment of the range of policies recommended under the FCTC must surely recommend. When public understanding of the industry’s methods is better understood, it is less of a problem, as fewer people are then prepared to take tobacco money. CSR is never necessary for a government – it can instead tax the industry or its products directly, to raise the same money.
 
* What is your advice to a true TC activist?
 
Tobacco control remains the most important preventable public health problem, so it is a most worthy cause. All too often, it can feel like an impossible fight; but a look back in history, even just over the last couple of decades, shows that persistence and ever wider information sharing pays results. When I started at ASH in 1979 I would never have believed that we would be where we are today. The war is far from won, but many important victories have been won already.
 
* Being a veteran in TC, any other comments, guidance or advice?
 
TC work can be very tiring and soul destroying, partly because of the enormous problem we are trying to tackle, and also because a huge and highly resourced enemy directly and actively opposes everything we do. But not only do we need to remind ourselves of progress to date, but also we need to keep fit and healthy. This includes taking time off work to refresh ourselves, rather than succumb to the temptation to work all hours; and to allow ourselves to be an active part of the better world we are working for.