Examination of witness (Questions 280
- 299)
THURSDAY 9 DECEMBER 1999
DR DEREK
YACH
Mr Burns
280. When did the WHO reach the conclusion that
cigarettes cause lung cancer?
(Dr Yach) Over the last I do not know how many years,
but since 1970, we have had resolutions on tobacco based upon
concerns about lung cancer. In 1970 the wording was "being
aware that there is a strong association, there are serious affects
of smoking in promoting the development of lung cancer".
By 1978 the wording was much clearer and it was in causal terms.
Every time since a resolution has been introduced to the World
Health Authority, and I thought I would leave the full list of
the resolutions for the Committee, there have been 17 resolutions
since 1970, those have reaffirmed and strengthened the evidence
base.
281. Would the same timescale apply for when
you believed that it was addictive, that nicotine was addictive,
or would that be different?
(Dr Yach) The timescale would be different. Again,
I think we should be aware that the knowledge and science of addiction
through the tobacco industry documents was strengthening through
the 1960s and 1970s. In the public domain the wording on habits
was still being used in a very lay, general sense. The first time
a deliberative committee of WHO actually made some decisive comment
about nicotine being a dependence producing substance as the result
of an expert committee, which is a very specific category in WHO,
was as recent as 1998. This is the committee report for you as
well.
282. What sort of data do you have on patterns
of smoking around the world?
(Dr Yach) We have very detailed data. One of WHO's
mandates in all fields of public health is to carry out surveillance.
A lot of the countries have weak surveys themselves but just to
give you a feeling for what we have available, and again it may
be something the Committee may want to have, so this is a gift
from WHO to the Committee—
Dr Brand
283. You are not trying to influence us, are
you?
(Dr Yach) This is available on the Internet. It provides
you with information on smoking status in all the countries for
which we have data. The basic picture we have got in very simple
terms is that if we take the last two decades for which we have
recent data, there are some countries which have shown sustained
declines—the UK is one of those countries showing a rate
of decline over the last two decades of about 1.6 per cent of
adult consumption per capita per year—compared to increases,
over the same period, of eight per cent per year for 20 years
in China, 6.8 per cent in Indonesia, almost five per cent in Bangladesh,
five per cent in Syria and so on. So we have very clear evidence
of declining consumption in parts of the world and rising rates
in others. The way you interpret that should not be to say that
the problem has been solved in the UK. You are coming off an extraordinarily
high base of smoking. The absolute number of deaths remains high
and will remain high for many, many decades to come. In the developing
countries the opposite is the picture, the smoking rates are extremely
high now and the death rates have yet to follow. To give you a
feeling of the numbers, we have four million deaths in the world
a year, four million, that is in all countries. By the 2020s we
estimate that there will be around ten million deaths and 70 per
cent of those will occur in developing countries. Just think that
the smokers of the 2020s are smoking today, they are alive and
smoking today, which means that we are going to face one of the
largest, if not the largest, public health challenges in the 2020s
and 2030s. To give you the extent of it, this eclipses the sum
total of deaths from malaria and tuberculosis and many other causes
of death worldwide.
Chairman
284. One of the worries many of us have in the
UK, and we have talked to people in the States similarly, is that
the more work we do in our countries on tobacco then indirectly
the more we are pushing the tobacco companies into the developing
countries in the way you have described. How do you see policy
makers in a country such as Britain addressing that question?
Obviously you have a global perspective rather than a narrow perspective
of one country but do you appreciate that it is a concern from
our point of view that that is indirectly a product of what we
may achieve within the UK?
(Dr Yach) I think the first point I must stress is
that we believe, and Dr Brundtland put this on the record, that
the UK Government White Paper was very important for us in WHO
for many reasons. It highlighted the need for global action. It
highlighted the need for global activities of companies to be
equivalent to those which are expected in the domestic markets.
That is something which could be pressed for even more strongly,
that whatever is acceptable public policy at home should be acceptable
public policy in the places in which your products are being sold.
There have been steps taken to inform your own UK missions about
the importance of this worldwide. We have other governments, like
the US, who have formally informed their missions, their ambassadors,
around the world that they should no longer provide support to
tobacco companies on their missions, rather they should be providing
support, when requested, to tobacco control. We believe there
are many other areas which are also mentioned in the White Paper:
support for developing countries, particularly those which may
be the markets of multinationals based in the UK, to strengthen
tobacco control through DFID, through your international development
programmes. We know that certainly the international development
programmes are starting to look at providing that support. One
of the biggest areas of concern in many of the poorer developing
countries is not only in those where tobacco use is a problem
but some where tobacco use may be minimal but tobacco growing
may be very important. I am referring particularly to Malawi and
Zimbabwe where they have a disproportionate amount of their foreign
exchange going into the selling of tobacco. There we believe that
we need to work very closely with UK agriculturalists, as well
as with your development agencies, to first of all ensure that
farmers understand that there is no dichotomy behind strong demand
reduction in all countries on public health grounds and looking
at the long term consequences for farmers because we realise that
there will not be an immediate effect of reducing demand. You
have seen the rates, the fastest the UK has gone is 1.7 per cent
decline per year. If worldwide we achieve rates of decline of
two to three per cent there will still be a large market for tobacco
farmers well into the 2020s, 2030s. We need to minimise their
concern and particularly their influence on government stopping
healthy public policy. There is an enormous amount that you can
do. I must say there is a lot that you are already doing. One
of the most powerful things to ensure is that the WHO Framework
Convention on tobacco control which is being worked on at the
moment is a convention that really stops trans-national actions
to promote tobacco use. That will mean that as individual countries
take strong action they will be doing it in concert with other
countries around the world.
Audrey Wise
285. Tobacco growing is subsidised in the EU.
This Committee took this up with the appropriate Commissioner
some years ago but without any effect. Do you think that when
we go to Brussels, as we will be doing in the course of this inquiry,
this is a point we should raise with the European Union Commissioner?
(Dr Yach) We absolutely believe it is. In discussions
with some Zimbabwean farmers we have indicated to them our belief
is first of all we realise there will be a long-term future unfortunately
for tobacco, smokers will be around for many, many decades, but
we hope that when the last smoker smokes a cigarette the tobacco
comes from a country like Malawi or Zimbabwe rather than a heavily
subsidised country in Europe or the USA. I need to emphasise as
well that the WHO has an additional new role in the UN system
and that is to act as the chair of a task force on tobacco control
of all UN agencies. That means that we chair a committee, including
the Food and Agriculture Organisation, including the World Bank,
including the IMF, and what we are trying to do through that committee
is define a single, coherent policy where you do not have these
contradictions, where on the one hand we are promoting demand
reduction in one set of activities and agencies ,and on the other
we are subsidising the very activities that undermine our own
policies. We believe that policy coherence is something that you
could play a vital role in ensuring in the European Union.
286. The tobacco companies clearly are conscious
of your influence and importance. The British American Tobacco's
Annual General Meeting was on 29 April this year and the Chairman,
Martin Broughton, made a speech in which he said that the World
Health Organisation's priorities are different from those of health
ministers in the developing world for whom issues like malnutrition,
lack of sanitation, infant mortality and AIDS loom much larger.
He says that, in fact, WHO is driven by a western agenda. What
would your reply to that be?
(Dr Yach) The WHO is an intergovernmental agency.
We represent the will of all our member states, 192. There is
virtually no other area of public health where there has been
so much international consensus by ministers involved in the will
as in the area of tobacco control. The proof of that is the 17
resolutions that have occurred over the last few years. To be
more specific, one of the areas of the world the tobacco industry
often cites as not being ready or ripe for tobacco control is
the African continent. What are the facts? What are the ministers
of Africa themselves saying? The truth of the matter is when they
assembled on 18-21 October this year in Cairo, they had an agenda
which focused on the need to address AIDS, malaria and polio as
well as tobacco. In their discussions on tobacco they acknowledged
the need for action on all the policies that are being discussed
in western countries and around the world, including increased
tax, bans on advertising and promotion, preventing people from
involuntary smoking, assisting farmers to diversify was one, adopting
the framework convention on tobacco control, all cabinet meetings
in Africa should be smoke-free, all buildings at the ministry
of health should be declared tobacco free, member states need
to report to the Organisation of African Unity on Progress in
implementing a long range of recommendations made by the ministers
of health. This was a relatively short meeting with a massive
public health agenda. They selected to highlight the importance
of tobacco as a public health problem because they know that somewhere
down the line they are going to face this problem and addressing
it early and vigorously is going to save enormous public resources.
The truth is that wherever we go there is not a single country
where increasingly the ministries of health and the ministries
of finance are not beginning to recognise that tobacco control
makes sound public health sense and sound economic sense. Our
colleagues in the World Bank released a report earlier this year
on the economies of tobacco control, again I think a very important
report because it compliments the public health perspective we
have. Remember, the World Bank's key people it works with are
developing countries as well as some of the transition economies.
The prescriptions of the World Bank are virtually identical to
the prescriptions of the World Health Organisation and we suspect
that those of the rest of the UN family will also become more
similar over time.
287. Of course, in countries where there is
malnutrition and terrible infant mortality, it would seem to me
that they get poorer if people are distracted into purchasing
cigarettes. In Britain certainly poorer people paradoxically are
more likely to spend some of their income on cigarettes. Presumably
you would agree that actually diverting national resources or
individual resources into buying tobacco is likely to make malnutrition
worse and infant mortality is not going to be helped by the low
birth weight effect of tobacco smoking by women?
(Dr Yach) I think there are a couple of points. There
is no question that in the developed world and in the transition
economies of Eastern and Central Europe, the Central Asian Republics,
many of the developing countries are moving very fast, like China.
Tobacco is now probably becoming one of the major causes of death
among the poor. Not only that, in Europe it is probably the predominant
avoidable reason of the social class gap in life expectancy between
the rich and the poor. So one means of reducing the social class
gap is good tobacco control. We would not want to oversell the
impact of tobacco in some of the poorest developing countries
amidst conditions of high levels of HIV AIDS, malaria and malnutrition
but what you are saying is absolutely vital for many countries
where tobacco is fast becoming one of the most important causes
of low birth weight. There are parts of South Africa, for example,
where calorie intake may be less important as a determinant of
low birth weight than the fact that in those populations up to
50 per cent of women smoke during pregnancy. Increasingly we are
finding that is the case in many parts of the world where we have
documented evidence from Brazil, from India and from other developing
countries showing how important tobacco use in pregnancy is as
a cause not only of low birth weight but of a range of other ill
health problems among children. At the request originally of the
G8 Ministers of Environment, we convened a meeting to look at
the impact of other people's smoke on low birth weight and on
children's health in January this year. We concluded that in developing
countries and developed countries this was a major neglected area
and means of improving child health on a worldwide basis.
288. Finally, you really have got the Chairman
of British-American Tobacco very angry. In that same speech he
said "The WHO seems to have been hijacked by zealots in its
desire to set itself up as some sort of super-nanny". Are
you zealots?
(Dr Yach) Obviously we are public health professionals
who look at the data, the data speaks for itself. Four million
deaths now, ten million deaths in the 2020s. I come from a general
policy background, the whole organisation has to balance the impact
of AIDS, malaria, many other terrible causes of death and disease.
Amidst that balancing Dr Brundtland believed the data itself spoke
clearly about the need for action, and fast action now. We believe
we are sticking to where the evidence guides us. Also we need
to address an impression often gained that the entire resources
of WHO are being turned to tobacco control and away from many
of the other problems of development and poverty. The truth of
the matter is that we are probably spending at the moment about
0.4 per cent of our budget on tobacco control which we think is
a modest, maybe too modest, investment in the major cause of death
in the 21st century.
289. Do you think perhaps some of the anger
expressed here derives from the fact that the tobacco companies
have failed to hijack WHO themselves?
(Dr Yach) I think the Committee will give us an answer
to that.
Mr Austin
290. No doubt you have observed the debate and
discussion that has gone on here about tobacco sponsorship, particularly
sport and the arts and the threat when the Government was considering
Formula 1 Motor Racing, that Grand Prix motor racing may be taken
out of the United Kingdom and go to Eastern Europe or somewhere
where such controls did not exist. I would like your comments
on that and, also, your view on the tobacco industry's shift in
focus generally from West to East and on the movement of cigarette
production facilities into the third world?
(Dr Yach) I think, first, on the question of sponsorship
and advertising, we are very convinced by the work of the World
Bank in carrying out probably the most systematic review of the
impact of advertising and promotional bans which are well documented
in this document Curbing the Epidemic. The basic message
that comes out of there is that a total ban makes the difference,
a total ban on advertising and sponsorship. When you leave these
windows of opportunity open, like sports sponsorship, one cannot
epidemiologically detect what the independent effect of a ban
on Formula 1 is relative to a complete ban. Our prescription again
tries to keep it very simple. The moment you start introducing
exceptions the doors open wide and you lead yourself into an endless
debate. Rather, the principle should be you should not be allowing
the sponsorship by companies of a product that kills half of its
users when they use the product regularly. To us that is a simple
fact, it is based as well on the evidence. The other curious thing
is that we are unaware of sports bodies or sports activities that
have ever suffered in the long run when sponsorship has been removed
by law. With regard to the shifts, I think there are a number
of ways in which the issue is portrayed. On the other hand, we
have people saying that the only reason the tobacco companies
are moving into the developing world is because of declining consumption
at home. We would disagree with that. The reason they are doing
that is to increase market sales, it is just sensible marketing
and sales practice. The way they are doing it though is to take
advantage of the weak regulatory and legislative environment in
many countries and they are using many of the approaches and methods
that have long since been legislated out in countries like the
UK or in Canada or in other countries. They are able to seek the
weakest parts of a market, to use marketing strategies that do
not exist in the UK. For example, you will have Benson & Hedges
being sold by women in flimsy golden dresses in discotheques in
Sri Lanka, handed out free. You would have other examples of fairly
blatant advertising using semi-clad women in Thailand to sell
cigarettes. Worse, in the Philippines you would have Madonna icons
used to sell cigarettes taking advantage of it being an inherently
Catholic country.
291. Which "Madonna" are you referring
to?
(Dr Yach) We are finding increasingly as well that
many of the entertainment people are joining the Tobacco Control
Group as well, so maybe that is something we should approach Madonna
the icon about. I think the concern is that we are seeing rising
levels of investment in marketing and distribution. As you said,
production is moving to countries where sales are increasing and
being encouraged to increase. A number of joint ventures have
been established right across Europe as well as with China. We
have been very concerned to see how Chinese trade delegations
to the UK are often received by tobacco executives in this country
and tobacco executives in this country lead general trade delegations
to China. This sends a very confused signal about the desirability
of British exports in tobacco leading the way in other fields
of exports which would be highly desirable. I think we are generally
concerned about the greater linkage occurring between multi-nationals
and many state monopolies within countries, particularly in China
as well as other parts of Asia.
292. You have mentioned certain countries providing
cigarettes free or at low cost. Is there any difference in the
way tobacco companies are acting than any other drug pusher in
that they are forcing a product on someone, getting them hooked
and then having a permanent market?
(Dr Yach) I do not think I would be qualified to answer
that.
293. On the price mechanism, the other question
I want to ask is are you aware of any international studies which
compare the effectiveness of differing rates of tobacco duty and
price mechanism on encouraging people not to smoke or reduce smoking
consumption?
(Dr Yach) Again we have had substantial work—I
am meant to be lending this one to you this time—and we
have had a number of reviews of the economics of tobacco control
and this is some of the source document that went into the final
World Bank report. The bottom line is very clear, for us the most
powerful means of reducing consumption is through the price mechanism
and that has its best effect particularly in youth and in poor
people. We find also that when there is earmarking of tax for
tobacco control activities, you have greater levels of public
acceptance and you have a sustained institutional capability in
countries to continue tobacco control beyond the pricing mechanism
into advertising, media communications campaigns and cessation.
The UK again has played a very important leadership role in earmarking
part of the exise tax. We know very simply as the price goes up,
consumption drops, revenues continue to rise. As the price drops
deaths increase and that is the very simple equation. It is the
case worldwide. It is the single area where WHO, the World Bank
and the IMF will be carrying one message to the Ministries of
Health and the Ministries of Finance worldwide increasingly as
this report starts being disseminated over the next 12 months.
294. Can I just pursue that. One of the issues
that has arisen here now in this country, because of the price
mechanism and duty, is the issue of illicit tobacco finding its
way on to the market due to smuggling, not through the acts of
small individuals but really clear evidence of a major criminal
conspiracy to smuggle goods in where of course the penalties for
so doing are much, much less and the risks much less than smuggling,
say, cocaine or heroin. Are there any lessons or advice you would
give to Government as far as the penalties for smuggling of tobacco?
(Dr Yach) I think you partly decided this by allocating
part of your excise tax to strengthen border controls and ensure
that there is not smuggling. It seems to be a very important and
sensible step which needs to be globalised. Smuggling is a criminal
activity and should be dealt with as such, with penalties being
appropriate to the fact that the product in the end is going to
kill its regular consumers. We find it very interesting that when
one looks at the relationship between countries where there are
high levels of smuggling and what is called the transparency index,
which is produced by Transparency International, which is a measure
of the general level of corruption in a country, the higher the
corruption index the higher the degree of smuggling, which suggests
we are dealing with a problem of organised crime which needs to
be dealt with as all forms of organised crime are dealt with.
The inappropriate response to smuggling is always to drop prices
which is, of course, the response the tobacco industry has requested
and suggested over many years. The reason we do not recommend
it is because, first of all, it translates into deaths and, second
of all, because we know price differentials are only one of a
range of reasons for smuggling across national borders. One needs
to address them fully in a more comprehensive manner. This is
an area which is fundamentally important for WHO as we start working
on the Framework Convention which needs to strengthen particularly
those aspects of tobacco control which slip through the cracks
due to globalisation.
Dr Brand
295. Can I return to a question which John Austin
asked. You clearly illustrated that the tobacco companies tailor
their marketing techniques to the Third World, escaping the tighter
regulation that might exist elsewhere. Are they doing the same
with the products that they actually sell in the Third World?
(Dr Yach) Do you mean are the tar and nicotine levels—
296. Yes?
(Dr Yach) First of all, the evidence is pretty scanty
on systematically collecting information on that but the information
we have shows that in general there have been pretty wide differentials
suggesting that tar and nicotine levels are generally higher in
the poorer and developing countries. This has not been available
on a systematic basis. It is something now that WHO, with a number
of agencies, is trying to gather.
297. It would be very helpful to have that as
evidence. The United States may well move towards a much tighter
nicotine content control which makes a less addictive cigarette
but it is in the interests of the companies presumably to sell
as many highly addictive products in the Third World to open up
their market.
(Dr Yach) I think again we will learn a lot about
this from the tobacco industry documents. We will probably see
how in a particular country over time they have adopted the contents
over time to meet what they want to, some concept of international
standards. The Centre for Disease Control is starting to do these
kinds of tests and they may very well have early information already,
comparative international information.
298. From your evidence, do you find that the
tobacco companies tend to work collectively in most of these instances?
(Dr Yach) Well, as I mentioned earlier, certainly
they have worked collectively in trying to develop policies around
WHO and the UN agencies. In a general sense they have certainly
worked collectively to deny the health evidence systematically
and now for the first time we are starting to have companies go
counter to that. They have probably worked together very carefully
in the area of product design and will probably find that has
been something which has been sustained over many decades.
299. Which makes a bit of a mockery of their
claim that advertising is just to encourage existing smokers towards
their brand.
(Dr Yach) Exactly.
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