1. Behavioural Issues in Chronic
and Communicable Diseases
By Dr Nik Nor Ronaidi bin Nik Mahdi

2. • Question:
Critically discuss the strategies of multi-
national tobacco companies in promoting
smoking behaviour particularly in developing
countries. To what extent can the state and
the community contest the power and
influence of tobacco companies. Illustrate
your discussion with the history of the
operation of tobacco companies in Malaysia.

3. Content
• History of tobacco use
• Epidemiology of tobacco use
• Tobacco industry efforts to thwart effective
tobacco control
• Conclusion

4. History of tobacco

5. History of tobacco
• 6000 BC - Tobacco began growing in Americas.
• Around 1st century BC, American natives began
finding ways to use tobacco (smoking, chewing
and in enemas)
• Tobacco was credited with almost miraculous
healing powers and was used by the natives of
America as remedy for aches, pains, snake-bite,
abdominal and heart pain, chills, convulsions,
epilepsy, skin disease and fatigue, among other
ailments

6. History of tobacco
• 1492 – Christopher Columbus discovers tobacco
smoking and takes it to Europe
• 1612 – Tobacco first grown commercially in North
America (Jamestown, Virginia)
• 1865 - The first commercial cigarettes (hand rolled
cigarettes) were made by Washington Duke →
sold to soldiers at the end of the Civil War

7. History of tobacco
• 1881 - James Bonsack invented the cigarette-
making machine → cigarette smoking became
widespread.
– He went into business with Washington Duke’s son,
James “Buck” Duke.
– The first brand of cigarettes were packaged in a box
with baseball cards and were called Duke of Durham.
• Buck Duke and his father started the first tobacco
company in the U.S called American Tobacco
Company → largest and most powerful tobacco
company until the early 1900’s

9. History of tobacco
• In early 1900’s, several other companies were
making cigarettes.
• In 1902 Philip Morris company came out with its
Marlboro brand.
• The wars were good for the tobacco industry.
– Soldiers overseas were given free cigarettes every day
– Cigarettes were also being marketed to women since
they became more independent during WW II
– Since WW II, there have been six giant cigarette
companies in the U.S. [Philip Morris, R.J. Reynolds,
American Brands, Lorillard, Brown & Williamson, and
Liggett & Myers (now called the Brooke Group)].

11. History of tobacco
• 1964 - the Surgeon General of the U.S. ( the chief
doctor for the country) wrote a report about the
dangers of cigarette smoking →nicotine and tar in
cigarettes cause lung cancer.
• 1965 - Congress of the U.S. passed the Cigarette
Labelling and Advertising Act→ every cigarette
pack must have a warning label on its side stating
“Cigarettes may be hazardous to your health.”
• 1971 - Tobacco companies were not allowed to
advertise cigarettes on television or radio.

12. History of tobacco
• 1980’s - the tobacco companies had come out with
new brands of cigarettes with lower amounts of tar
and nicotine and improved filters to keep their
customers buying and to help reduce their fears.
• 1980’s - governments, and private companies have
begun taking actions to restrict cigarette smoking in
public places.
• 1984 - Congress passed another law called the
Comprehensive Smoking Education Act → cigarette
companies had to change the warning labels on
cigarette packs every three months.
– four different labels created to rotate.

14. History of tobacco
• State taxes on cigarettes have also increased
• As it becomes more difficult for tobacco companies to sell
their products in the U.S., they are looking outside.
• For the last two decades, tobacco production is declining in
the developed countries
• On the contrary, tobacco production in the developing
world is consistently increasing.
• U.S. tobacco companies are now growing tobacco in
developing countries such as Africa, India, Pakistan,
Philippines, Thailand, and Indonesia.
• Fifty percent of the sales of U.S. tobacco companies go to
Asian countries, such as Thailand, South Korea, Malaysia,
the Phillipines, and Taiwan.

18. Epidemiology of tobacco use

19. Epidemiology of tobacco use
• Since at least the colonial era, tobacco has been a
popular commodity in US, with tobacco use
increasing almost exponentially from the 1800s to
the mid-1960s
• The invention of the cigarette fueled this dramatic
rise in tobacco consumption, and cigarette smoking
quickly outpaced the use of any other form of
tobacco product (chewing tobacco, cigars).
Why?
– cigarettes served as a more efficient vehicle for the
absorption of nicotine
– less expensive form of tobacco

20. Epidemiology of tobacco use
• The number of adult smoker increased almost
exponentially until its peak in 1963
• This growth in consumption was driven largely by:
– mass production of cigarettes;
– the mildness, packaging, addictiveness, and convenience
of the product;
– glamorization of smoking in movies and on television;
and
– persuasive advertising campaigns

21. Epidemiology of tobacco use
• Tobacco consumption among Americans have
greatly reduced since the publication of the first
Surgeon General’s report on the harmful effects of
cigarette smoking in 1964.
• By 1983, the annual per-capita consumption of
cigarettes had declined approximately 20% from
the 1963 level to 3,494 cigarettes per adult;
• By 2004, it had declined an additional 49% to 1,791
cigarettes
• The prevalence of adult cigarette smoking also had
declined to half in 2005 as compared to 1965.

26. Epidemiology of tobacco use
• Four stages of tobacco epidemic:
– Stage 1:
• Low prevalence (below 20%) of cigarette smoking, principally
limited to males, with no apparent increase in lung cancer or
other chronic diseases caused by smoking.
– Stage 2:
• increases in smoking prevalence to above 50% in men, early
increases in cigarette smoking among women
• increasing burden of lung cancer and other tobacco-
attributable disease in men
• Tobacco control activities are usually not well developed, the
health risks of tobacco are not well understood, and there is
relatively low public and political support for the
implementation of effective tobacco control policies.

27. Epidemiology of tobacco use
– Stage 3:
• Marked downturn in smoking prevalence among men, a more
gradual decline in women
• The burden of smoking attributable disease and death
continues to increase.
– Stage 4:
• Marked downturn in smoking prevalence in both men and
women.
• Full damage caused by cigarettes

29. Tobacco industry efforts to thwart
effective tobacco control

30. • The tobacco companies are among the world’s
most sophisticated and successful marketers.
• They spend billions of dollars to promote their
deadly products, prevent governments from
protecting their people and mislead tobacco
users and potential tobacco users

32. Political influences
• In US, the tobacco industry spends millions of dollars trying
to influence public policy.
• Occurs through quiet, behind the scenes, insider strategies.
• It makes major contributions:
– to elected officials and political parties,
– payments to governments to support infrastructure such as mass
transit
– large investments in sophisticated public relations campaigns
– gives money to civic, educational and charitable organisations
• In turn the politicians help the tobacco industry.

35. Political influences
• Eg: In an attempt to boost its market share in
Indonesia, Rothmans Indonesia sold 5 % of its
equity to Mr Sudwikatmono, a cousin of President
Suharto, whose family controlled huge sections of
the Indonesian economy and whose patronage is a
virtual guarantee of commercial success
• What about Malaysia?

36. • Malaysian scenario:
– While the government has pledge its commitment to promote
healthy living and discourage smoking, on the flip side, they have
opted to engage and collaborate with tobacco companies in
promoting anti-smoking campaigns
– Health activist are questioning the government half hearted
measures in tobacco control and the tobacco industry’s
involvement in the orchestration of anti-smoking campaigns
which contrastingly leads to an increasing prevalence of smokers
– Malaysia’s history of tobacco control is pockmarked with the
failures of adopting of an ad hoc policy and collaborating with
tobacco companies , favouring industry guidelines over
legislations and protecting tobacco cultivation
– Government also issuing licenses to local companies to produce
cheaper local cigarretes (e.g: John, Saat, Bromax)
(FOMCA’s Position Paper on Tobacco Control in Malaysia, 2006)

37. • Malaysian Scenario
– In January 1982 the Malaysian government took another
step forward in tobacco control and announced a ban on
the direct advertising of imported brands over RTM and
pushed back the advertising time for locally
manufactured brands till after 10 pm.
• Direct lobbying of top level officials in several ministries,
pushing for support for its counter-proposal and providing
arguments against either a complete ban or a more punitive
restriction on cigarettes. The CMTM received assurances the
proposal would receive support from the Ministries of Trade
and Industry, Primary Industries, and Agriculture.
• It only take the industry just five months to defeat the original
decision.

41. • Malaysian scenario:
– Regarding the issue of indirect advertising and
sponsorship, tobacco companies gain support from the
very top leadership in Malaysia including the King, the
Prime Minister, and cabinet ministers.
• discourage efforts to ban indirect advertising in Malaysia.
– E.g:
• Marlboro’s sponsorship of motor racing events, for example,
assisted the Prime Minister in his quest to bring Formula 1 to
Malaysia. The Marlboro Malaysian Grand Prix in April 1997
was flagged off by the Prime Minister. In 2001, Formula 1
racing was held in Malaysia for the first time.
• In the mid 1990s RTM was earning about 40% of its advertising
revenue from tobacco companies and the Minister indicated
the station could not do without tobacco money.

42. Economics arguements
• Tobacco industry often argues that tobacco control will
harm the national (or regional) economy.
• They claim that tobacco farming, manufacturing,
distribution and sale constitute a vital part of the economy
and that if smoking is eliminated, the country will suffer
substantial job losses, incomes will fall, tax revenues from
tobacco will disappear, and international trade will suffer.

43. Economic arguments
• In the developing world, tobacco companies actively
promote the economic benefits of tobacco farming to local
economies and farmers.
• The industry-sponsored tobacco farmers’ lobby group, the
International Tobacco Growers’ Association, served as a
front for lobbying developing countries at WHO.
• Exaggerate the economic significance of tobacco growing
for the farmers :
– the global price of tobacco is relatively stable compared with other crops.
– In addition to the cash revenue, strong support in kind is also provided by the
tobacco industry in the form of material and advice.
– the industry often gives farmers loan.
– other crops may cause farmers problems with storage, collection and delivery.
Tobacco is less perishable than many crops, and the industry may assist with its
delivery or collection; by contrast, late collection, late payment, and price
fluctuations may blight other crops.

44. Global Tobacco Control website
(http://www.globalink.org/)

45. Economic arguments
• Does increase in cigarettes taxes promote
smuggling activities?

46. Economic arguments
• Taxation is one of the most effective measures for
reducing tobacco consumption.
• The tobacco companies oppose tax increases. More
and more, they rely on the argument that higher
taxes are an incentive for smuggling.
– increased cigarette taxes will reduce legal sales, but not
total sales (legal and illegal sales combined)
– increased taxes will lead to increased smuggling,
resulting in less revenue for governments
• Both Canada (1994) and Sweden (1997) have
reduced taxes on tobacco in response to concerns
about smuggling.

47. Economic arguments
• According to the World Bank, the experience of a large
number of high-income countries shows that, even in the
face of high levels of smuggling, tax increases bring
increased revenues and reduce cigarette consumption
(Jha P, Chaloupka F. Curbing the epidemic: governments and the economics of
tobacco control. Washington, USA: World Bank, 1999)
• Tobacco industry benefits from smuggling activities:
– smuggling stimulates consumption both directly (through the
street sale of cheap cigarettes) and indirectly (through pressure to
lower or keep down taxes)
– the treat of smuggling has also been used to avoid trade barriers
or to force open new markets.

48. Economic arguments
• As expected, tobacco companies are actually
involved in smuggling activities:
– Since 1997, there have been several court cases and
official investigations in different part of the world which
accused the industry of supplying the smuggled
cigarettes or at least of being aware of the illegal
destination of their products. E.g.:
• A former BAT executive was found guilty by the Hong Kong’s
High Court for his role in his role in an operation that smuggled
cigarettes into China.
• In 1998, a major tobacco company was convicted for actively
breaking the law to assist in a smuggling operation.
• An affiliate of RJ Reynolds International pled guilty to charges
of helping smugglers illegally reroute export cigarettes into
Canada.

49. Allies, third parties and front groups
• Fighting tobacco is not a one to one battle
• The tobacco industry has many business allies and third parties with which it works
to block implementation of effective tobacco control legislation and programmes.
• Allied and third-party industries that have opposed tobacco control include:
– hospitality
– gambling and gaming
– advertising
– Packaging and transport
– chemical production
– tobacco retailing
– agriculture and tobacco growers
– labour unions
– investment advisers
– recipients of tobacco sponsorship and research funds

50. Marketing strategy
• Explore market in developing countries
• Tobacco companies provide benefits to the retailers
– sales incentive programmes
– promotional discounts
– attractive display units
– incentives for prominent placement products in their
shops

51. Scientists and researchers
• Tobacco companies realized the important role of
scientists and researchers in developing public
policies for tobacco control.
• Tobacco industries are either:
– Funding research to produce favourable results, to
suppress unfavourable findings, and to give alternative
explanations for diseases associated with tobacco use
– Attacking scientist and researchers by portraying them
as extremist, unqualified and politically motivated,
denigrating and humiliating them to superiors,
publishers and the public, bringing lawsuits, and working
to cut off funding.

52. Scientists and researchers
• E.g:
– In 1991, Glantz and William Parmley published their
reseach in the journal Circulation, which concluding that
secondhand smoke caused approximately 53,000
nonsmoker deaths a year, including 37,000 from heart
disease.
• Consultant Larry Holcomb wrote to the Circulation paper
arguing that Glantz and Parmley drew stronger conclusions
from the epidemiological studies than was warranted and that
the studies failed to control for confounding variables like diet.
• Walter Decker, also wrote Circulation arguing that the studies
Glantz and Parmley considered were methodologically flawed
and criticized them for including studies published in foreign
languages.

53. Promoting and Advertising
• Cigarettes are the most heavily advertised product in the
U.S. (4 billion dollars a year)
• In 2000, British American Tobacco (BAT) and Japan Tobacco
International (JTI) were the first and third largest
advertisers in all Malaysian mass media, respectively,
spending some 160 million Malaysian Ringgit
(Audit Bureau of Circulations News, March 2001).
• The purpose of cigarette ads and promotions:
– to make sure smokers keep smoking
– get people who quit to start smoking again
– to increase the number of cigarettes people smoke each day
– encourage women and young people to start smoking

54. Promoting and Advertising
• Promotion:
– sponsor sporting, art, and music events
– scholarships (e.g: British American Tobacco Malaysia Foundation
Scholarship)
– donations to organizations (e.g: National Association for the
Advancement of Colored People, the National Urban League, and
Goodwill Industries)
• The advertisements are very successful
• According to U.S. Surgeon General, every day 3,000 teens
smoke their first cigarette
• Examples of popular cigarette ads among people:
– R.J. Reynold’s advertises Camel cigarettes with the cartoon figure “Joe Camel.”
– Philip Morris’ Marlboro cowboy ads
• one of the cowboys pictured in Marlboro ads, Wayne McLaren, died of lung
cancer. He died in 1992 after smoking for 25 years.

55. • Malaysian scenario:
– In January 1971, the Singapore government imposed a complete
ban on all forms of cigarette advertising
– Singapore then made overtures to the Malaysian government to
also ban cigarette advertisements over RTM, which could be
received by Singaporeans
– The Malaysian government brought together the several relevant
ministries, health professionals, and the tobacco industry to
discuss a proposal to ban tobacco advertising
– The industry asked for ‘‘…additional time to study the issue before
making alternate proposals’’
– The decision was postponed until for six years.

60. Conclusion

61. Conclusion
• Fighting against tobacco industry is very challenging
– Involved high political influences from top leadership
– Involved so many allies and third parties
– Efforts from tobacco companies to counter attack
• The tobacco industry is not and cannot be a partner
in effective tobacco control.
• The industry’s fight against tobacco control in
Malaysia is consistent with its global strategies.

62. THANK YOU

63. References
• R.C. Jiloha (2008), Tobacco Use: Health and
Behavior, New Delhi, New Age International (P)
Limited.
• Richard J. Bonnie, Kathleen Stratton, and Robert B.
Wallace (2007), Ending The Tobacco Problem: A
Blueprint For The Nation, Washington DC, The
National Academic Press.
• Judith Mackay and Michael Eriksen (2002), The
Tobacco Atlas, London, The Halfway Press.