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2011 23: 70Asia Pac J Public HealthAshleigh Cussen and Judith McCool

Options for Accelerating ProgressTobacco Promotion in the Pacific: The Current State of Tobacco Promotion Bans and

  

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DOI: 10.1177/1010539510390925http://aph.sagepub.com

Tobacco Promotion in the Pacific: The Current State of Tobacco Promotion Bans and Options for Accelerating Progress

Ashleigh Cussen, BHSc Hons1, and Judith McCool, PhD, MPH1

Abstract

Tobacco consumption is a major contributor to the burden of chronic noncommunicable disease within the Pacific region. Low and lower-middle income countries are acutely vulnerable to exploitation by the tobacco industry as they often lack the resources and capacity to implement protective tobacco control policies. The Framework Convention on Tobacco Control, which has been signed by 14 Pacific Island Countries and Territories, was introduced in 2004 to guide the priorities for tobacco control policy implementation. Legislation, tobacco industry documents, and peer-reviewed journals were evaluated to assess the current status of tobacco advertising bans of the 8 low and lower-middle income countries within the Pacific region. Results identified that of the 8 Pacific countries reviewed, 3 had comprehensive tobacco advertising bans that prohibit tobacco advertisements in 5 to 7 forms of media, and the remaining 5 countries have weak tobacco advertising bans that provide no protection for youth against tobacco advertising. This research reveals the need for resources to support the introduction of effective policies around tobacco advertising in the low and lower-middle income countries within the Pacific region.

Keywords

Framework Convention on Tobacco Control, FCTC, marketing, Pacific region, tobacco, tobacco industry, youth

Background

The Western Pacific Region (WPR) is currently witnessing the fastest increase in tobacco initia-tion across all World Health Organization (WHO) regions.1 Approximately 30% of the world’s smokers reside in the WPR, where it is estimated that 2 people die every minute from diseases

1University of Auckland, Auckland, New Zealand

Corresponding Author:Ashleigh Cussen, Heart Foundation, National Office, 9 Kalmia Street, Ellerslie, PO Box 17160, Auckland 1546, New ZealandEmail: AshleighC@heartfoundation.org.nz

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related to tobacco consumption, which accounts for approximately 20% of all deaths for the region.2 Although the WPR includes large tobacco consuming countries, such as China and Japan, estimates of current smokers in the Pacific Islands countries and territories (PICTs) range between 17% and 49%.3 The high prevalence of smoking among youth in the Pacific (as high as 53.7%) underscores the urgent need to address both the supply (trade of tobacco products) and demand (tobacco promotions) of tobacco products, which are directly associated with increased exposure to noncommunicable disease (NCD) risk factors.4 The advent of 2 key global frame-works—The Global Agenda for NCD 2008-2013 and the WHO Framework Convention on Tobacco Control (FCTC)5—provide a platform to accelerate political leadership on tobacco con-trol and other NCD risk factors in the region. However, despite the fact that a high proportion of Pacific Islands have signed and ratified the FCTC, it is uncertain whether this action has not been reflected in a reduction in smoking prevalence. In this article, we assessed the status of tobacco promotion bans (Article 13 of the FCTC), in 8 of the 14 Pacific countries that have signed and ratified the FCTC.

Exposure to cigarette advertising and other promotions is strongly implicated as one of the primary predictors of smoking uptake among young people.6,7 The association between exposure to smoking or cigarette advertising or promotion and uptake of smoking is consistent with fun-damental principles of advertising, which is premised on the theory that witnessing an action will result in the desire to imitate that action.8 Advertising of tobacco products, like most other com-mercial products, has evolved from an explicit announcement of product merit toward symbolic association between product and identity. The evidence linking exposure to tobacco advertise-ments and promotions and consequential smoking behaviors is well established.9,10 The conclu-sions of this evidence find that tobacco promotions are a deliberate and highly effective means of registering product names and images with young people. The associated social desirability of the product contributes to establishing smoking as normative and essential to a desired self-image.11,12

Tobacco control authorities and researchers have paid close attention to tobacco promotions in several countries where stringent regulation of tobacco promotion has been legislated through policy.13 The progression (from unregulated marketing practices to highly regulated tobacco promotions) has been largely reliant on the commitment of individual countries to the enforce-ment of tobacco promotion bans, which almost always form one part of a more comprehensive tobacco control program (M. Hale, unpublished data). Fundamentally, the FCTC was developed as a global response to the tobacco epidemic. The profound escalation of tobacco use within low and lower-middle income countries prompted the development of this global framework to offer protection from the harms of tobacco use.4 Parties to the FCTC are encouraged to use it as a tool for coordination in the roles and services of tobacco control initiatives and as leverage to address tobacco consumption.13 Within the Pacific region, the FCTC provides these relatively isolated countries with a potentially useful framework for strengthening public health policies around tobacco control.

The article reflects the current status of youth tobacco consumption and current government activities regarding tobacco promotions within 8 low or lower-middle income Pacific Island states and territories (M. Hale, unpublished data). The low income countries include Papua New Guinea and the Solomon Islands; the lower-middle income countries are Kiribati, the Marshall Islands, the Federated States of Micronesia, Samoa, Tonga, and Vanuatu.14 With the populations of these countries varying between 100 000 (in Kiribati) and 6 000 000 (Papua New Guinea) and spread across vast areas of ocean, the Pacific region faces unique challenges related to tobacco control. Almost all these countries experience some degree of geographic isolation, and all these countries currently exhibit high rates of tobacco consumption among both adults and youth. Within the context of a rapidly changing social and economic environment, governments in PICTs are also adapting to globally driven tobacco control guidelines and frameworks.14 However,

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the implementation of comprehensive tobacco advertising bans within low and lower-middle income Pacific Island countries has been slow.

MethodThis study analyzed both peer-reviewed and “gray” literature that addressed the effects of tobacco consumption, tobacco consumption prevalence (on global, regional, and national levels), tobacco advertising bans, and tobacco control policy. The review included the following search engines: Medline, PubMed, SocioFile, electronic databases (Tobacco Legacy Documents, PM, Brown and Williamson, RJ Reynolds), and hand searches of peer-reviewed publications and Web sites. The search of literature was limited to articles published or translated into the English language. Policy documents and legislation from low and lower-middle income PICTs and tobacco industry documents made available through the 1998 Master Settlement Agreement between major transnational tobacco corporations (Philip Morris, Brown and Williamson Tobacco Company, Lorillard, and RJ Reynolds) and the State Attorneys General of the United States were also reviewed. These documents were accessed through the Internet using a word search of keywords, titles, abstracts, authors, recipients, and original document location. The review was constrained by the studies on tobacco control conducted within the Pacific region.

Search TermsBecause of the immense size of the collections of both tobacco industry documents and published literature, searches for documents relative to the topic were narrowed using a combination of the following key words: Youth, Adolescent, Advertising, Ban, Legislation, Pacific Island, PICT, Promotion, Policy, Pacific, Teen; Targeting Tobacco, Cigarette, Smoking, Kiribati, Marshall Islands, Federated States of Micronesia, Papua New Guinea, Samoa, Solomon Islands, Tonga, Vanuatu.

ResultsThe results of the review of tobacco promotions within 6 WPR countries are presented by country in alphabetical order: Kiribati, Marshall Islands, Papua New Guinea, Samoa, Tonga, and Vanuatu. Table 1 describes the key features or levels of tobacco promotion attainment in reference to the FCTC Article 8.

Table 1. Forms of Tobacco Advertising Banned Through Legislation in Selected Pacific Island Countries

Country Television Radio Print Movies OutdoorPoint of Purchase Sponsorship Level of Ban

Kiribati — — — — — — — WeakMarshall Islands — — — — — — — WeakFSM — — — — — — — WeakPNG O O X O — — — WeakSolomon Islands — X — — — — — WeakSamoa X X X X X O X ComprehensiveTonga X X X X — — X ComprehensiveVanuatu X X X X X X X Comprehensive

Abbreviations: FSM, Federated States of Micronesia; PNG, Papua New Guinea. —, No legislation; O, Mentioned in tobacco control legislation, but not clearly defined or regulated; X, Banned.

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Kiribati

A census conducted in 2005 showed that 32% of young males aged 15 to 19 years smoke regu-larly. This prevalence of tobacco consumption reflects the high density of tobacco outlets in the capital, South Tarawa. A 2005 study conducted by the Demography Section of the SPC found there to be a total of 245 tobacco outlets within the capital.15 Despite a lack of current evidence, Kiribati is reported to have a high prevalence of tobacco consumption among both adults and adolescents, with rates of smoking among youth anticipated to increase.

Kiribati currently has no legislative provisions to control tobacco advertising. To implement a sustainable tobacco advertising ban policy, the persistent issues of perceived cultural inappro-priateness of the ban and inadequate funding for tobacco control programs need to be addressed. Because of the association of tobacco with spiritual beliefs and the use of tobacco as a gift for older male villagers and the gods, the government is fearful of the repercussions of legislative tobacco control as this may be considered offensive to both the highly respected older men of the population and to the gods they worship.16 Nonetheless, the signing and ratification of the FCTC marks a milestone in Kiribati’s fight against the tobacco epidemic, and Kiribati is in the process developing legislation to support the implementation of the FCTC.17-19 No tobacco is grown in Kiribati, and therefore, any tobacco advertising ban that is enacted is expected to have limited negative impact on the country’s fragile economy.16

Because of the strong cultural importance of tobacco consumption to the people of Kiribati (known as the I-Kiribati), the implementation of a comprehensive tobacco advertising ban at this stage seems unlikely. Within Kiribati, tobacco advertising legislation is essential to denormalize the cultural and social acceptance of tobacco. Support of tobacco advertising bans by neighbor-ing countries are important to encourage the Parliament of Kiribati to consider the damaging effects of tobacco use within the country. Nongovernmental organizations such as the Secretariat of the Pacific Community can assist Kiribati to develop a broad tobacco control program within which education programs and advertising bans are essential.20

Marshall IslandsA school-based survey of 3294 Marshallese students in grades 5 to 12 conducted in 2000 found an overall smoking rate of 10.8%.21 The survey included students in both urban and outer atoll schools, finding higher smoking rates among outer atoll students (14.5% compared with 9.4%). This disparity could be the result of poor transportation and communications limiting the ability of tobacco prevention and cessation programs to reach these isolated atolls.

In the Marshall Islands, the tobacco industry has been extremely aggressive in its marketing, using advertising and contests (offering prizes of cash, pickup trucks, and boats) to encourage smoking initiation. The cash sums offered in tobacco industry–sponsored contests can be up to $10 000, a substantial sum when the average full-time teacher in the Marshall Islands earns approximately $6000 per annum.22 There has also been widespread distribution of tobacco-branded clothing and sponsorship of games and activities.22

Fortunately, the role of the tobacco industry within the Marshall Islands has been well docu-mented as the government of the Republic of the Marshall Islands filed a lawsuit against US tobacco companies in 1997.22 The lawsuit sought to gain compensation for the costs incurred from tobacco-related illness and disability. Although the final ruling was in favor of the tobacco companies, a positive outcome of the litigation was increased data collection on smoking preva-lence in the Marshall Islands and increased awareness of the activities of the tobacco industry in the Pacific.22 Although the impacts of the actions of the tobacco industry within the Marshall

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Islands are well documented no formalized governmental restrictions on tobacco advertising have been implemented.

Papua New GuineaAkin to the considerable prevalence of adult smokers, the prevalence of smoking among youth in Papua New Guinea is very high. As part of the Global Youth Tobacco Survey (GYTS) conducted in 2007, of the 1867 students surveyed in grades 6 to 9, 61.6% had ever smoked cigarettes and 53.7% of the students reported to be current users of a tobacco product, with 49% current cigarette smokers. A further 19.8% of the students consume another form of tobacco.22 Prevalence of tobacco consumption is higher among male youths than female youths. An earlier study conducted in 1998 found that tobacco use among university students was also “a frequent occurrence.”23

The Tobacco Products Health Control Act (1987), which is in part intended to restrict the advertisement of tobacco products, provides Papua New Guinea with a weak tobacco advertis-ing ban. The overall aim of the Act is to control the consumption of tobacco products.24 Although there is some form of tobacco advertising ban legislation within the country, this does not appear to affect youth exposure to tobacco advertisements, with 85.2% of the participants in the GYTS reporting having seen a cigarette advertisement on a billboard in the 30 days preceding the survey and 82.8% reporting having seen a cigarette advertisement in a newspaper or maga-zine within the same period. At the time of writing this article, the Tobacco Products (Health Control) Act 1987 prohibits print advertising, that is, newspaper and magazine-based tobacco advertisements are prohibited.25

To strengthen current tobacco advertising ban legislation, the government of Papua New Guinea has been encouraged to amend the Tobacco Products (Health Control) Act 1987 by writ-ing in plain unambiguous language. This development would further curtail the opportunity for the tobacco industry to argue against the meaning of some parts of the legislation and will clearly define what is legal within the State of Papua New Guinea. To substantially move toward a com-prehensive tobacco advertising ban legislation, the Act needs to be amended to specifically include the words “film,” “video recording,” “telecast,” and “broadcast.” In anticipation of future developments in technology and information systems within Papua New Guinea, prohibition of tobacco advertisement on the Internet and within other electronic media could also be included. Because of the country’s reliance on imported materials, Papua New Guinea also needs to initi-ate a ban on cross-border tobacco advertisements.25

SamoaA 2007 survey of Samoan students between the ages of 13 and 15 found that 26.4% of the stu-dents surveyed had ever smoked cigarettes, the number of males having ever smoked being 29.9% and the number of females being 20.9%. A total of 16.8% of the students currently smoke cigarettes and 19.7% currently use another form of tobacco. Although the prevalence of youth smoking in Samoa is lower than some lower-middle income PICTs, 29% of Samoan students surveyed who had never smoked were planning to initiate smoking within the next year, indicat-ing that tobacco consumption as an issue among Samoan youth.26 Youth in Samoa have high rates of exposure to tobacco product advertising on billboards and in the print media (newspapers and magazines), with 69.8% and 70.5% of students being exposed to these advertisements each month, respectively.27

As part of the government’s work to reduce tobacco consumption within Samoa, the Tobacco Control Act was enacted by the Parliament of Samoa in 2008, focusing mainly on the following:

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protect Samoan citizens from the health risks associated with exposure to environmental tobacco smoke; regulate the direct and indirect marketing, promotion, distribution, advertisement, and sale of tobacco products; and monitor and regulate the presence of harmful ingredients in tobacco products.27

The prohibition of tobacco advertisements within media identified in the Tobacco Control Act 2008 details the bans in clear, unambiguous language and does not allow the tobacco indus-try the ability to manipulate the terms and the language of the Act. Although the current legisla-tion is forceful in preventing tobacco advertisements in 6 of the 7 media (using the definition by Chaloupka and Saffer28), this legislation does not provide full protection for the youth of Samoa from tobacco advertisements in media imported from other nations.27 Point-of-purchase adver-tisements are also not currently prohibited.

TongaIn Tonga, tobacco is widely available, and tobacco use has been identified as the most critical factor in the nation’s incidence and experience of NCDs.29 A 2005 analysis of tobacco outlet density conducted by the Demography Section of the Secretariat of the Pacific Community in the capital of Nuku’alofa found there to be 245 tobacco outlets.29 This availability is reflected in the high rates of youth smoking. A 1991 survey of smoking prevalence among 20 to 24 year olds found that 60.4% of males and 9.8% of females smoked.30 A later study in 2007 involving Tongan school students aged 11 to 17 found that among boys 15% had ever smoked, of this group, 10% smoked on a weekly basis and 19% smoked daily. Among girls of the same age 16% had ever smoked, of which 9% smoked on a weekly basis and 6% smoked daily.30

The government of Tonga has been predominantly supportive of tobacco control initiatives and is approaching the issue of competing health priorities by integrating tobacco control initia-tives with activities aimed at reducing NCDs.31 This is in part due to an Minister of Health who is strongly focused on preventive health measures; therefore, the country has the critical political backing to introduce tobacco control (and other health promoting) policies. Indeed, the National Non-Communicable Disease Committee has 4 working committees, one of which focuses spe-cifically on tobacco use. Tonga has proposed (but not introduced) an increase in tobacco product taxation to assist the committee, which is at present dependent on volunteers from nongovern-mental organisations.29

Many forms of tobacco advertisements are already banned under the Tobacco Control Act 2000.29 The Tobacco Control Act 2000 places bans on advertising in radio, television, film, print, and in the form of sponsorship, but there remains scope for strengthening the parameters of advertising, namely, on point-of-purchase and cross-border advertising. Nonetheless, the Act has clear, unambiguous wording and acknowledges the influential and deceptive nature of tobacco advertisements.

VanuatuThere are more than 80 islands that make up the archipelago of Vanuatu. The small island nation has a population of approximately 243 304 people, and 40% of the population in 2004 was below the age of 15.30 Among Vanuatu youth aged 13 to 15 years, 28% have ever smoked cigarettes and 18.5% are current cigarette smokers.31 Other forms of tobacco are also popular among youth in Vanuatu, and 14.3% currently use a form of tobacco other than cigarettes. Vanuatu is unique in terms of its youth tobacco consumption profile, as a slightly higher percentage of female youths consume tobacco than male youths.31 A survey conducted in 2007 revealed that an alarming 62.8% of 13 to 15 year olds that had never consumed tobacco were planning to begin smoking within the next year.32,33

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An analysis of tobacco outlet density conducted by the Demography Section of the SPC in 2005 found that the capital Port Vila had 393 tobacco outlets.32 Although the Republic of Vanuatu has worked toward developing robust legislation that encourages public commentary on the harms of tobacco and acknowledges the issues of youth smoking, there are many sections of the Tobacco Control Act 2008 that allow the tobacco industry room to subvert the intentions of the Act. In progressing toward a more protective tobacco advertising ban, the government of Vanuatu must work toward removing the sections of the Act that permit industry donations and funding of indi-viduals and other organizations, and tobacco product placement, as challenged by Chaloupka and Saffer.28 Although Vanuatu prohibits the production of transnational tobacco advertisements within its borders, there also needs to be a clause banning the importation of media and materials that contain tobacco advertisements.

DiscussionThis study reviewed tobacco advertising legislation within 8 low and lower-middle income PICTs. Our findings identify significant variation between the 8 PICTs in terms of the levels and strengths of tobacco advertising bans. Samoa, Tonga, and Vanuatu have recently introduced comprehensive tobacco advertising bans on 6, 5, and 7 forms of tobacco advertising, respectively. The Parliament of the Solomon Islands has developed the Tobacco Control Act 2010, which is intended to place stronger regulations on the supply and demand of tobacco within the island nation.34

Although these 3 countries have acted quickly to implement Article 13 of the FCTC, there are many loopholes and ambiguities that prevent their tobacco advertising legislation from provid-ing youth with complete protection from tobacco advertising.

In contrast to the comprehensive tobacco advertising bans of Samoa, Tonga, and Vanuatu, the 5 remaining low and lower-middle income PICTs have weak tobacco advertising bans, with no or one form of media clearly defined and prohibited. Kiribati, the Federated States of Micronesia, the Marshall Islands, Papua New Guinea, and the Solomon Islands report high rates of youth smok-ing, which may be in part due to unregulated tobacco industry activity through youth exposure to tobacco advertisements.20-22

Tobacco use in the Pacific has complex associations with cultural practice, economics, and trade.20 Although the rich culture of the I-Kiribati must be respected at all times, the leaders of the small island nation need to begin to work to transform cultural perceptions of tobacco to ensure future generations have reduced risk of smoking and therefore have longer, healthier lives.

However, the rise of tobacco use among young people in the Pacific calls for an alternative approach and one that takes full advantage of FCTC and the Tobacco Free Initiative MPOWER to steer away from a dependence on tobacco income and the formation of cultural dependency on tobacco. The 2009 WHO Regional Meeting in Hong Kong explicitly identified the need for greater investment in the practical application of the FCTC to ensure the benefits of this global treaty reach those countries that most need this support.16 The FCTC also provides Pacific gov-ernments with a common framework to work with in a way that acknowledges the unique needs and cultures of the Pacific. In practice, this may mean adapting and strengthening existing tobacco advertising bans to ensure loopholes are not open to exploitation by the tobacco indus-try. The development of regional collaborations and forum (such as the annual NCD forum) can provide ideal opportunity for countries, who have limited resources for tobacco control, to estab-lish stronger tobacco advertising bans as a region.

ConclusionsAcross the 8 low and lower-middle income PICTs, the presence and level of tobacco advertising ban legislation is varied. Kiribati, the Republic of the Marshall Islands, and the Federated States

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of Micronesia had no form of tobacco advertising legislation, despite high rates of youth smoking. Although Papua New Guinea and the Solomon Islands have some form of tobacco advertising legislation, the ambiguity of the wording and low level of media regulated renders these policies ineffective in reducing youth exposure to tobacco advertising.

In contrast to the lack of protective policy in 5 of 8 PICTs, Samoa, Tonga, and Vanuatu have recently introduced comprehensive advertising bans across a wide range of media. If consis-tently enforced, the bans have the capacity to severely limit the avenues for the tobacco industry to access the youth population. At present the effects of the comprehensive tobacco advertising bans within these 3 countries are unknown; the lack of surveillance and monitoring of tobacco use before and after the introduction of the advertising ban precludes attribution of effect.

To develop regionwide protection from tobacco advertising for Pacific youth, low and lower-middle income PICTs need to build capacity for tobacco control through utilizing the FCTC as a tool for political engagement. The language used in Tonga’s Tobacco Control Act of 2000 provides a useful template for introducing watertight legislation for tobacco control and could be used a regional guide. Individually, low and lower-middle income PICTs can strengthen efforts to control tobacco advertising through development or adjustment of legislation that clearly defines the parameters of tobacco advertising bans and eliminates use of ambiguous wording. Inclusion of a ban on both imported and exported cross-border is vital to limit tobacco industry presence in the Pacific region.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research and/or authorship of this article.

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