[Intl-tobacco] MINUTES OF EVIDENCE: Examination of witness: DR DEREK YACH

[Robert Weissman]

MINUTES OF EVIDENCE: Examination of witness: DR DEREK YACH
Source: House of Commons, Wednesday, 2/2/00
Examination of witness (Questions 259 - 279)=20

THURSDAY 9 DECEMBER 1999=20

DR DEREK YACH

Chairman

=A0=A0259. Good morning. Can I welcome you to this session of the Committee=
=2E
Can I particularly welcome Dr Yach and thank you on behalf of the
Committee firstly for your written evidence and for your willingness to
come rather a long way to meet us this morning, we do appreciate that. I
wonder if you would like to briefly introduce yourself and say a little
bit about the WHO in the context of work on tobacco and your own role
within the work of that organisation?


(Dr Yach) Thank you. We also appreciate the opportunity to participate in
this. My name is Derek Yach. I am from the World Health Organisation where
I am the Programme Manager for what is called the Tobacco Free Initiative.
This is one of the two new Cabinet projects that Dr Brundtland initiated
when she took office as Director General of the WHO in July last year. The
prime focus of it is to try to increase advocacy and action for tobacco
control on a global basis. The decision to do that was based upon the
extraordinary evidence of human health impacts around the world. My past
activities have been for three years in the World Health Organisation as
leading an international consultative process on policy development, that
is all policy development not just in relation to tobacco, and previous to
that I have been involved in a range of community based community health
research and epidemiological activities in South Africa.

=A0=A0260. Thank you. I wonder if I could immediately focus on to an area
which has obyiously become one of the most important areas of our
investigation. That relates to the tobacco industry's internal documents.
You refer to these internal documents in your evidence to us. If I can
just quote from your evidence. You say: "Only one of the tobacco companies
in the UK, the BAT Group, has been subject to significant document
disclosure requirements (through US litigation and through the US
Congress). In addition, even with respect to the BAT Group, the
disclosures are in need of supplementation; for example, most of the
document disclosures from BAT Group were subject to a 1994 cutoff date and
should be supplemented with more recent documents." I wonder if you could
say a little bit about your views of the significance of these documents
and the point about supplementation post-1994. How do you believe that
this Committee can be of assistance in addressing the contents and
implications of these documents?


(Dr Yach) I think that for many years we have felt in tobacco policy that
we have had to work in the dark. The tobacco industry documents provide us
for the first time, in the words of our policy adviser, Judith MacKay, to
really walk through the minds of the tobacco industry. The equivalent for
us in tobacco, the problem we face, can be seen if you think of malaria.
There is no possibility of advancing malaria research and policy if you do
not understand the mosquito, its structure, its function, how it works. We
now have that opportunity for our programme, which is the tobacco
industry. Since the documents started becoming available in the early
1990s and particularly over the last few years it has helped us understand
the science of addiction, it has helped us to understand the way in which
international, WHO and NGO policy has been thwarted, the way the research
direction has been undermined. It has put in the eyes of the public the
truth about a range of facts that previously we only had suspicions about.
What it is basically doing is it is making the potential for an
international dialogue on the true policy very transparent. We believe
that will help the policy debate at a global level. Many governments
around the world are now looking at the tobacco industry documents from
their perspective to find out in their country how has it been that they
have had such difficulties in the past in introducing advertising bans or
restrictions, trying to move the excise tax process forward. We have found
through many of the documents very detailed strategies developed by the
tobacco industry over many years to try to thwart that policy process. So
we believe that this is an incredibly important resource equivalent to the
epidemiological data which actually put the health case out in the first
place. Whereas many of the documents in the US and that have been based in
the US are now in the Minnesota depository and have been put on-line and
are available both by the tobacco industries based in the US as well as by
the Government, the US Department for Justice, the Centres for Disease
Control, they have all provided support to scan all the documents, the
same has not occurred with regard to those that are based in the UK. The
first limitation is public access. The intention of the US court case was
to make it fully accessible. There is a physical reality in the case of
BAT Co`s UK d++epository limited space, limited time, complex searching
ability. Making the material available through the Internet we believe is
the best and simplest solution. It would mean that everybody would have
equal access. It would mean that you would have a fully transparent
system. We believe that BAT may have has already scanned all of its
documents and this may be something that you would want to ask them about
so that you would save the costs of having to scan them yourselves. In
addition, the deadline of 1994 was set by the US court cases. This inquiry
is happening at the end of 1999. We believe that it needs to be
supplemented with information from all the tobacco companies that are
selling products in the UK until the point at which the inquiry completes
its deliberations.

=A0=A0261. You would presumably argue that we have so far only slightly lif=
ted
the curtain on what is available. What do you think the significance would
be of completely drawing back the curtain in relation to the moving of
policy, not just in this country but globally on tobacco policy?


(Dr Yach) The people who we speak to involved with tobacco products
regulation have fairly sound reason to believe that the science of
addiction, the science of tobacco product modification, has been
considerably advanced within the tobacco industry and much of that has not
seen the light of day. We would save enormous public resources by having
that information now and not having to repeat a lot of research that may
be required.

=A0=A0262. Can I just interrupt. To simplify what you are saying, you are
implying that the tobacco companies could have produced a much safer
product a long, long time ago but chose not to. Or have I misunderstood
what you are implying?


(Dr Yach) Yes, that is correct. We have good reason to believe, again
going back for many years, tobacco companies agreed not to compete in the
area of safety and improved health consequences. There were no economic
incentives then for any individual company to do that.

=A0=A0263. So there was a cross-industry agreement on this issue?


(Dr Yach) We believe that there was. I think the documents that we already
have at our disposal show that has occurred in many areas of research,
that denial of the evidence has been done jointly by many of the
companies, the way in which the direction of research in their own areas
has occurred, the way many of the animal experiments, the mouse house in
Germany and others were closed down. That was all when lines of research
were leading into areas where they did not want it to proceed. I need to
explain where WHO is in the question of product modification. We must
admit that we have come to realise relatively late the critical importance
of this as an additional component of comprehensive control. Dr Brundtland
announced to the international regulatory authorities in Berlin this year
that she would be convening a scientific meeting to look at what do we
know about the basis for setting stronger product modification rules. That
meeting will be held in Norway in February. Many of your own scientists
will be present at that meeting. Part of the problem we have is that not
all of the evidence will be on the table because some of it is still being
held within the vaults of the tobacco industry.

=A0=A0264. You have referred to the Guildford documents.


(Dr Yach) Yes.

=A0=A0265. Have you accessed those documents? What problems do you perceive=
 in
respect of public access? What assistance might this Committee offer in
terms of not just accessing the Guildford depository but also the other
archives that you have obviously referred to in respect of other
companies?


(Dr Yach) First of all, with regard to the US based companies, I think
that access has improved considerably. Philip Morris, for example,
provided updated information until late 1998/1999 under the terms of the
settlement. Much of the material is on-line. We have sent some of our
staff to Guildford and in the initial searches, really being able to go
through only a few thousand documents, we have found some of the most
important information showing the way in which the tobacco industry worked
globally compared to the US where probably a lot more of the science is
based. So from an international perspective we would regard what is really
contained in Guildford as being crucial for many of our developing
countries, particularly those, of course, where BAT has historically
played an important role. The same probably occurred elsewhere. Step one
must be to see whether the documents have already been scanned and, if
they have, to make them available on the Internet. Step two would be if
they have not been scanned to ensure that we find the public resources to
scan them. We believe the costs would be minimal compared to the enormous
public benefit. We also believe that a range of research institutions,
public and private, should be encouraged to work together with the British
Government to actually make that a high priority to occur very fast. We
are currently involved in developing the first international treaty WHO
has ever been involved in. That will focus on tobacco control. We need
that evidence as the treaty making process starts moving ahead. We would
also hope that UK institutions, your Medical Research Council and others,
for example, would see this as a legitimate area for public funds to be
used to do research on the benefits of using the tobacco industry
documents to advance public policy. The National Cancer Institute for the
National Institute of Health has invested reasonable funds in making this
an important research topic in the US. So this is now regarded as the
appropriate line of research to advance cancer control as well.

=A0=A0266. Over and above pursuing the research issue, clearly in the State=
s
the action that has been taken arising from the Minnesota action has
resulted in a significant amount of money accruing to individual states
from the settlement. Some of the states have used this money to invest in
anti-smoking policies in quite a detailed and radical way. Do you see the
access to records issue possibly leading on to similar litigation
elsewhere outside the States, possibly in this country and other countries
that globally would be concerned with the tobacco issue?


(Dr Yach) A number of countries have approached us for support with regard
to finding out whether litigation is a sensible option. Our advice is very
simple: we support those activities that advance public health goals. The
primary focus of litigation should not necessarily be to regain fund money
per se, but to ensure that healthy public policies are put in place. The
truth and the information coming out of the documents in itself,
independent of the funding, we believe is a means of advancing that policy
debate. The answer is absolutely clear that many countries are seriously
considering litigation in different forms. There are already a number of
court cases under way. The Indian Supreme Court is one of those examples.
We suspect that over time they will recognise that fundamental to any
court case is the ability to have information about the behaviour of the
tobacco industry and certainly in the case of many of the multinationals
that would be very important, as with other UK companies.

Dr Brand

=A0=A0267. A quickie on this. You said that the cost would be minimal compa=
red
to something. Would you speculate and put a figure to putting the
Guildford documents on-line?


(Dr Yach) Sure.

=A0=A0268. Because clearly that is the raw material from which further
research can then be done. That is for the scientific bodies. The actual
getting the stuff in the public domain, how much would that cost?


(Dr Yach) We would estimate, based upon roughly how many pages of
documents there are and how much the scanning costs are, we are probably
talking about $2 million to $4 million as a single cost for scanning the
material and making it available on the Internet. The comparison would be
against the hundreds and hundreds of millions of dollars going into all
forms of treatment and other research activities and tobacco control which
are run either by the Medical Research Council or the Wellcome Trust or
others.

Mr Burns

=A0=A0269. Earlier in one of your answers you were talking about your belie=
f
that the companies at some point had joined together to stop progressing
any further research in certain areas. Do you have any actual concrete
evidence of this or is it more anecdotal?


(Dr Yach) No, it is not anecdotal. I think one of the earliest documents
goes back to 1980 when a document prepared by the tobacco industry
stressed the role of ICOSI, which stands for the International Commission
on Smoking Initiatives and was formed by the tobacco companies in the
1980s. One of the goals stated by them=97we will leave the document numbers
with you=97was "the first initiative on a worldwide scale to counter the
actions of anti-smoking groups". That was their professed aim. Under it
they then went on to disclose what specific steps they should take. These
were then elaborated further in a range of documents, including one of
those held in a conference in Boca Raton in 1988 sponsored by Philip
Morris but joined by many of the other companies where Geoffrey Bible, who
was then the President of Philip Morris International and now is the Chief
Operating Officer of Philip Morris, talking about WHO stated "this
organisation has an extraordinary influence on government and consumers
and we must find a way to defuse this and reorientate the activities to
their prescribed mandate. In addition, we need to think through how we can
use our food companies' size, technology and capability with governments
by helping them with their food problems and giving us a more balanced
profile with the government than we now have against WHO's powerful
influence". They went on in the document to talk about the International
Labour Organisation. The aim of their plan was to inhibit corporation of
ILO into WHO's anti-smoking programmes and to take urgent steps to contact
worker and employer leaders of these groups in the ILO governing bodies.
One last comment: also in the same period the Boca Raton plan discussed
"countermeasures designed to contain, neutralise, reorientate the World
Health Organisation" and stated "the necessary resources should be
allocated to stop WHO in their tracks". Because of this Dr Brundtland felt
this was such a serious influence on WHO historically that it hampered us
being able to move ahead with great enough clarity and in October she
called for an inquiry into the way in which WHO and the UN systems have
had their policies thwarted by the industry and appointed a member of our
executive board, Dr Zeltner, who is Head of the Federal Swiss Health
Department, to head the inquiry which will be getting under way very soon.
This is unprecedented. I need to say that the World Bank has also joined
the inquiry and has nominated a top anti-corruption expert to join the
inquiry.

Chairman

=A0=A0270. Would that inquiry have any bearing on the way in which individu=
al
governments, such as our own, may have had their efforts thwarted by the
tobacco companies over the years?


(Dr Yach) The terms of reference are mainly to focus on the international
domain. Dr Brundtland made it clear in her statement that we would hope
that individual governments would carry out their own separate inquiries.
I think this is an excellent example of one which would be able to
contribute to what WHO is doing and, similarly, I think our insights at
the global level will also help to put in perspective the importance of
this national initiative as having global relevance.

=A0=A0271. So you would be urging us to press the British Government to
establish a similar inquiry, but we had ministers in this place in 1954
actually talking about the connection between smoking and ill health. It
has taken so long for any meaningful initiatives to be brought in. You
would see that as very relevant?


(Dr Yach) Very relevant. I think we have to realise the global relevance
of the work done by Sir Richard Doll and colleagues afterwards, that is
regarded as ground breaking globally important research right from the
1940s and early 1950s. We have looked to the UK epidemiologists to provide
the lead on tobacco, and have received it, and increasingly they have
played an international role as well.

=A0=A0272. You used the word "corrupted" in terms of how your organisation =
had
been prevented from being effective on this issue. Do you believe that
other governments and parliaments have been corrupted by the influence of
the tobacco companies?


(Dr Yach) We believe certainly the policy process has been thwarted and
certainly we would be able to show that there have been severe efforts to
stop policies being put in place that are regarded as simply sensible
public policies by WHO, the World Bank and its member states. There would
be many, many examples of that.[2]

=A0=A0273. Have you any examples in respect of where the British parliament=
ary
system and the British Government system has been thwarted by the kind of
influence that you are talking about?


(Dr Yach) No.

=A0=A0274. That is what we are looking at here.


(Dr Yach) No, I do not have any of that. I can assure you that probably
many of the people who will give evidence here would have a better insight
from an individual national perspective.

Audrey Wise

=A0=A0275. I just want to refer to the practicalities of these documents at
Guildford because it has been made very clear to us, and you are
reinforcing it, that the current arrangements are hopelessly inadequate
with very limited time and very limited space for researchers to go in.
There are a lot of documents. I think I understand that you are saying
very clearly that it would be money well spent to have the whole lot put
on the Internet.


(Dr Yach) Yes.

=A0=A0276. Now, I have taken serious note of that and I am sure the Committ=
ee
has. We have also heard informally and while we have been in the US this
question has come up a great deal, as you can imagine, and we have
wondered whether there is anything short of that that would be useful.
Suppose we made an attempt to be more selective about what we asked for,
would there be anybody who could guide us as to how we would select the
most important documents? Or is it really very important to have the whole
lot?


(Dr Yach) I think, given the dramatic advances in information technology
and the electronic searching capability, our advice would be to get the
whole lot because you can never be entirely sure of setting the right
questions and the right search parameters. I think we have found great
difficulty even using the available searching ability to find things and
often they crop up under different categories that you do not suspect. I
do not think that there will be a cost saving, there may in fact be extra
costs in being more selective, whereas at least getting the material on to
the Internet and then applying our minds using the best of library science
to search better, as well as to have access to the indexes used by the
tobacco companies themselves, would save an enormous amount of time and
effort. There are, of course, many experts we could put you in touch with
who would be able to either verify this or give further detailed
information on the problems they have faced in searching through documents
for many years, those involved in the court cases in the US for example
and in Canada.

=A0=A0Audrey Wise: I think that would be very useful.

Mr Austin

=A0=A0277. In answer to the Chairman's question you actually used the phras=
e
that the research direction had been "undermined". Was this merely as a
result of the non-disclosure of the information that was available to the
tobacco companies or by some other means?


(Dr Yach) I think we know in the case of environmental tobacco smoke, for
example, that the research process has been affected in many ways: the
setting up of many bogus or front groups involved in research paid by the
tobacco company to try to ensure that no association was found. This has
happened in the US, in Japan, in Germany, and I am sure in the UK. The
funding of enormous amounts of symposia to try to continue to ensure that
the passive effects of tobacco on human health were not actually brought
to the public domain. The fact that when large scale European research
studies were carried out by our own sister agency, the International
Agency for Research on Cancer, there were fairly sustained efforts to try
to find out who were the researchers, could they influence them, could
they thwart the direction? There are many documents, not one or two but
tens of documents, that have shown how they were particularly concerned
with the European study showing that the impact of environmental tobacco
smoke in Europeans was much the same as it is elsewhere, because of the
consequences for smoking in public policies moving faster in Europe. In
the other areas of research there were examples of animal research which
was stopped in its tracks because they realised reading through the
documents that these would not look very good if they were ever made
public.

=A0=A0278. You are actually saying that it is not just the withholding of t=
he
information but they set out deliberately to create false facts on the
ground.


(Dr Yach) Yes.

=A0=A0279. To mislead.


(Dr Yach) This is described particularly in the Minnesota court case and
the documents coming out of the Minnesota court case and others.



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2=A0=A0 Note by witness: I did not use the word "corrupted".=A0Back


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=A9 Parliamentary copyright 2000 Prepared 2 February 2000

Select Committee on Health Minutes of Evidence


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Examination of witness (Questions 280 - 299)  THURSDAY 9 DECEMBER 1999 DR
DEREK YACH

Mr Burns

=A0=A0280. 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.

=A0=A0281. 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.

=A0=A0282. 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=97

Dr Brand

=A0=A0283. 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=97the 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=97compared 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

=A0=A0284. 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

=A0=A0285. Tobacco growing is subsidised in the EU. This Committee took thi=
s
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.

=A0=A0286. The tobacco companies clearly are conscious of your influence an=
d
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.

=A0=A0287. 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.

=A0=A0288. 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.

=A0=A0289. Do you think perhaps some of the anger expressed here derives fr=
om
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

=A0=A0290. No doubt you have observed the debate and discussion that has go=
ne
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.

=A0=A0291. 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.

=A0=A0292. You have mentioned certain countries providing cigarettes free o=
r
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.

=A0=A0293. 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=97I am meant to be lending thi=
s
one to you this time=97and 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.

=A0=A0294. Can I just pursue that. One of the issues that has arisen here n=
ow
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

=A0=A0295. 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=97

=A0=A0296. 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.

=A0=A0297. 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.

=A0=A0298. 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.

=A0=A0299. Which makes a bit of a mockery of their claim that advertising i=
s
just to encourage existing smokers towards their brand.

(Dr Yach) Exactly.




=A9 Parliamentary copyright 2000 Prepared 2 February 2000

Select Committee on Health Minutes of Evidence


------------------------------------------------------------------------

Examination of witness (Questions 300 - 307)  THURSDAY 9 DECEMBER 1999 DR
DEREK YACH

Mr Gunnell

=A0=A0300. I would just like to ask you what you think of the ISO standards=
,
the International Standards Organisation standards for measurement of
cigarettes? Is that data of use to consumers? Have you made any
representations to ISO and what would you like to see happen? Is WHO
represented on the relevant technical committee or is it still purely
dominated by the tobacco companies?

(Dr Yach) When we started this initiative, which was only 18 months ago,
we recognised pretty soon that the whole area of product design required
us to understand the measurement methods used by ISO in detail. We tried
to gain official status in the committees, in the particular committee in
the Tobacco Control 126 Committee of ISO. Only very recently on 20 October
in their last Committee they agreed to give WHO Category B liaison which
allows us for the first time full access to all their documentation. Our
concerns are exactly what you are saying that, first of all, it is
interesting that the delegations coming from countries tend to be
dominated by the tobacco industries. In the case of the UK it would
include delegates from Imperial Tobacco, Philip Morris, BAT, Gallaher's
and so on. In many cases the government regulatory person would not even
be represented. Many of the governments are solely represented by tobacco
companies, this is the group that finalises the measurement methods and I
think there has been outstanding work done by colleagues in this room and
elsewhere showing the shortcomings of the measurement methods which I am
sure they would go into in greater detail. The bottom line is that as we
move into the area of product modification we need to know what we are
really measuring and at this stage we have very good reason, from the
evidence coming out of the court cases, to believe we are not measuring
what is biologically the real dose and impact of all the carcinogens and
components of cigarettes.

=A0=A0301. So the consequences of you at least having the status you have n=
ow
gained in that is that you can expose the measurements=97

(Dr Yach) We certainly think that there will be a useful purpose in
entering into very serious dialogue through our new status and how we are
going to pursue that is still to be finalised. If we are going to move to
an international approach to product modification it is essential that
this be done pretty quickly. ISO has official status with WHO. Obviously
ISO has activities across a wide range of public health measurements. They
are a non-governmental association in official relations and attended the
Framework Convention meeting, so that dialogue has literally just begun.

=A0=A0302. The documents from Minnesota showed that young people were being
targeted in the west. To what extent is this happening in the west still
and to what extent is it happening today in the east? That does not just
apply to young people, it applies to women as well, which is an area where
you still have many non-smokers.

(Dr Yach) First of all with regard to children, we are concerned that
smoking rates are rising among young people in many developed and most
developing countries. The problem has not yet gone away. If the tobacco
industry had the full will to stop sales to children we believe it could.
There are a range of measures that it could truly introduce that would be
highly effective in combination with Government=97and this cannot be done
without strong government action. We reviewed the evidence on what works
to reduce youth consumption in a meeting in Singapore earlier this year
and came to the conclusion that the best means of stopping youth
consumption continuing to rise is by applying strong tax measures, total
advertising and marketing bans on advertising of products, providing youth
with the means to quit. A higher proportion of youth worldwide want to
quit than we have ever suspected and yet we are not providing the services
for them to do so. Similarly, we should use counter-advertising measures
that are driven, directed and worked on by youth themselves. Clearly one
of the key issues we fail to do is to think of what really appeals and
what is going to make a difference in youth groups and that is something
which we believe some of the campaigns like the Florida "Truth" Campaign
showed could make a difference. We would have to think worldwide how we
can do this more effectively. We hosted a meeting two weeks ago in Kobe,
Japan which included senior representatives from the Commission on the
Status of Women, the Convention on the Elimination of Discrimination
Against Women and the outcome of that meeting was grave concern about the
fact that on a worldwide basis 12 per cent of women smoke as opposed to 47
per cent of men and that is seen as a massive marketing opportunity for
the tobacco industry. From the women's organisations' perspective, they
believe this represents one of the greatest preventive potentials for
public health in the next century and if we could maintain and reduce the
rates of smoking among women by women providing the leadership role in
tobacco control, since clearly we men have failed, I think we may very
well find that the long-term public health consequences of tobacco would
be averted in the next century. I can leave with you the outcome of the
Kobe Declaration which will be carried forward into the follow-up Beijing
conference on women and development.

=A0=A0303. I believe that it is a compliment to describe WHO as a
"super-nanny". Do you feel that in order to get effective work in this
area we have to abandon the idea of voluntarily moving forward our no
smoking policies and we must introduce an element of compulsion into the
activities which surround passive smoking? We cannot make progress without
some compulsion from government and we should not be afraid of being
described as a "nanny state".

(Dr Yach) I think we would entirely agree. We have seen that governments
who have moved from voluntary agreements to hard law have had greater
success. At the international level we have had these resolutions over the
years and we are now moving for the first time to a treaty. In 50 years
history of WHO they have never used their outlaw option of a Convention,
the equivalent approach we will be taking to the need in controlling
biological weapons or major environmental risks to the environment. We
believe that that is the level of seriousness that we need if we are
really going to make a difference for all countries.

Audrey Wise

=A0=A0304. I would like to pursue the question of women. It is my observati=
on
that in this country in the past smoking was regarded by some women as a
sort of expression of emancipation, i.e. you could be like men and do what
men do. I was told by a woman doctor in America last week that there had
been an advertising campaign there directed at women which says "Get a
voice" and this is expressly to do with smoking. Are there any equivalent
things happening, as far as you know, in the marketing ploys in other
parts of the world? There will have to be improvements made to the status
of women. Is the desire for women to advance being manipulated in
marketing in other places?

(Dr Yach) Yes. That is happening in virtually every country undergoing
development in the world and the tobacco industry are very skilfully using
the aspiration of women to seek greater political involvement, to play a
greater role in all aspects of society as a means of increasing their
sales and marketing. So in Japan you will find advertisements aimed
particularly at women moving into the employment sector in greater
numbers. You will find that across the world. What was presented in Kobe
as well was the most extraordinary review in advertisements over the last
20, 30, 40 years of how the shift has been to focus more and more on the
issues of emancipation in advertising and marketing. You just have to look
at the women's magazines to start seeing how this is occurring. They are
playing on the themes of emancipation, the themes of thinness and slimness
and many of the other themes, the desirability of achieving an American
lifestyle when at exactly the same time the rates in many parts of the US
are declining among women and people are recognising the dangers. We would
urge that the video tape of this material may be something you should have
a look at. It was produced by the Robert Wood-Johnson Foundation, which
was the primary founder of tobacco control at a foundation level in the US
and within ten minutes you immediately have a pretty good insight into the
way in which they are working. As I said, I will leave with you the Kobe
Declaration produced mainly focusing upon women. Many of the people who
came to the meeting represent major international women's organisations
who had never ever been involved in tobacco and did not see this solely as
an issue to do with women in development. They left feeling this is a
major neglected area requiring global action. Again, many of the major
thinkers are based in the UK and need to be exported to carry the message
worldwide.

=A0=A0305. So we have got to get across to women that there is no liberatio=
n
in dying like a man.

(Dr Yach) Exactly.

Chairman

=A0=A0306. That is one way of putting it, Audrey. Dr Yach, I would like to =
ask
one final question before we finish. We are meeting officials from the EC
next week. Do you have any specific thoughts on the role of the EC in
respect of tobacco policy and the areas that our Committee should be
addressing when we meet with officials in Brussels next week?

(Dr Yach) The EC has a unique position now in the WHO Convention as a very
special case of an inter-governmental agency itself representing the will
of EU members and they can play a very strong leadership role in ensuring
that the 15 Member States speak as one and speak at the highest possible
level of tobacco control from a public health point of view. They are also
thinking very deeply about the area of product modification. I think they
need to be encouraged to continue their work in concert with WHO, which is
something we know is happening. As they start thinking about the accession
countries and the countries who are likely to become members over the next
decade I think we should emphasise to them the fact that this is the time
for them to bring their tobacco control policies in line with that which
applies within the European Union. Many of those countries are focusing at
this stage on the financial requirements for joining, but they need to
recognise there will be many other Directives, the advertising one being
an important starting point. We would see the EC as a vital partner
alongside the Member States and at this stage we would regard our
relationship as extremely good. The other issue is the issue that you
raised, Ms Wise, and that is the need to ensure you have a coherent
approach to tobacco control across all sectors and that does require
decisive leadership and that is the kind of leadership Dr Brundtland seems
to have been able to install in many national leaders. You cannot continue
agricultural subsidies simultaneous with trying to profess the need for
strong public health measures against tobacco.

=A0=A0307. Can I thank you for your very helpful evidence and for your
participation in this inquiry and for the documents that you have been
good enough to give us. We are most grateful to you. Thank you very much.
=A0=A0 (Dr Yach) Thank you.




=A9 Parliamentary copyright 2000 Prepared 2 February 2000