where law meets health

China has declared a national ban on smoking in select public places effective on May 1st, 2011. The ban is part of China’s effort to fulfill the WHO-supported Framework Convention on Tobacco Control treaty they’d signed in November 2003, which included a pledge to ban smoking in all public places by January 9th, 2011.

Dr. Sarah England, head of the WHO’s Tobacco Free Initiative in China, says that the new smoking ban will cover a much broader range of venues than in previous guidelines. The previous guidelines included movie theaters, concert halls, libraries, and malls; the new bans will now add hotels, restaurants, cafes, bars, salons, parks, museums, and other indoor public spaces to the list. Tobacco will no longer be sold in vending machines, and no-smoking signs will be displayed in public areas where smoking is banned. New regulations also ask owners and managers of those restricted venues to have staff members discourage smoking when they see it.

Although people like Dr. England acknowledge these steps as important in moving the China toward a national smoke-free policy, they’re also expressing serious concerns and doubts as to the regulations’ practical efficacy. The current definition of “public places” still does not include factories, government offices or other workplaces, and while there are threats of fines up to 30,000 yuan ($4,600) for “certain” violations, a comprehensive and specific penalty policy has yet to be defined. Past attempts to ban smoking have proven almost completely ineffective: thousands of smokers regularly lit up in front of “No Smoking” signs at Shanghai’s World Expo and Beijing’s 2008 Olympics, and in a city like Shanghai with roughly 20 million people — many of them smokers — only five people were penalized for smoking. And aside from those two special events, smokers in China have made it a regular habit to ignore no-smoking signs displayed in front no-smoking areas from hospitals to waiting rooms to elevators.

Part of the problem is how deeply engrained smoking is woven into the social and economic landscape of modern Chinese culture. One third of China’s population smokes; that’s a total of 350 million smokers, which makes up a third of all the world’s smokers – and the number of new smokers in China is only increasing with each new year. Home to the largest tobacco company in the world, China is also the world’s biggest cigarette manufacturer, selling one third of all the cigarette products in the world. The China National Tobacco Corporation alone produced up to 2.3 trillion cigarettes in 2009. This means that cigarettes serve as a significant source of revenue for the Chinese government, and indeed, in 2009, China’s tobacco industry generated roughly RMB 513 billion (US $77 billion) in taxes and revenue, which made up more than 7.5% of the central government’s total revenue that year.

Still, with a reported 1.2 million Chinese people dying from tobacco-related deaths every year – a number that is predicted to grow to 3.5 million by 2030 - China’s health officials argue that medical costs for health issues will soon surpass the revenues from tobacco by up to 20%. “Even if it’s not stringently enforced in the beginning, having a law is an important place to start,” said We Yiqun, deputy director of the Think Tank Research Center for Health Development.

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Editor: Bill C-393 has been lauded by Access to Medicines advocates, but nobody has given a simple statement about what it actually changes. We wrote this article to address that issue.

Bill C-393 passed in Canada’s House of Commons on March 9, and now awaits the Senate vote. The bill makes significant reforms to Canada’s Access to Medicines Regime, or CAMR. CAMR allows the Canadian government to issue compulsory licenses on domestic brand-name medicines so that cheaper generics can be exported to developing countries. Unfortunately, the current application process is embedded with bureaucratic complications, and CAMR has been left with the reputation of being virtually “unusable.” Indeed, many of the key current requirements of CAMR are more restrictive than the expressed guidelines of the WTO and TRIPS.

Bill C-393, called the “one-license solution” by its advocates, eliminates many of these extra restrictions.
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Editor: Tobacco litigation has brought into the spotlight, at least recently, information about the tobacco industry’s practices. We present, in a legible format, findings of fact by the federal judge presiding over US v. Philip Morris, a seminal tobacco case.

1999: the government initiates its first federal case against large tobacco companies. UNITED STATES OF AMERICA v PHILIP MORRIS USA INC. commences.

This case is important. Tobacco companies have been completely successful fending off lawsuits for three decades. Very recently, however, victories both in and out of court have uncovered mountains of internal tobacco documents. This finally provides the evidence the Department of Justice needs to prosecute the tobacco industry. Their goal: to punish the industry for decades of fraud. They cannot seek money for past medical damages, but will try to prove fraud and show that the industry has been in violation of RICO, the Racketeer Influenced and Corrupt Organizations Act.
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Editor: It’s important to understand a little bit of the history of tobacco litigation. The tobacco industry has been very effective at fending off legal challenges. The United States has been pivotal in initiating litigation against manufacturers; legal victories against the tobacco industry in the US have carved a model for public health lawyers.

It’s helpful to look at the history of tobacco litigation in three waves:

The first two waves are characterized by a highly successful scorched earth trial strategy, described by R. J. Reynolds’ attorney J. Michael Jordan:

“[T]he aggressive posture we have taken regarding depositions and discovery in general continues to make these cases extremely burdensome and expensive for plaintiffs’ lawyers, particularly sole practitioners. To paraphrase General Patton, the way we won these cases was not by spending all of [R.J. Reynolds’] money, but by making that other son of a bitch spend all of his.”
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Editor: Chronic diseases are now prevalent worldwide. We wanted to provide you with a snapshot of the spread of tobacco globally, its effects on global health, and efforts by states to mitigate tobacco’s harms.

Tsight of someone pulling out a cig in the middle of a crowded Borders café would be bizarre. And if that someone were bold enough to “light up,” furrowed stares would immediately laser all through the café. Indignant whispers would swish around the room. Finally, the café barista will walk over and gently ask the perpetrator to please go outside, 20 feet away from the store, to smoke.

But careful! Situated directly across from Borders is Marshalls, and 90 degrees to Borders and Marshalls is Target, all of which require the distance of at least 20 feet between the smoker and each respective building. As the smoker huddles outside in the winter cold, puffing away in his one allotted square foot, the patrons in Borders stare out at him through frosty big windows as if he’s some rare zoo specimen in its natural (and small) habitat.

California is not a friendly place to smokers.
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An ounce of prevention is not always worth a pound of cure. Though public health advocates are very vocal about prevention programs, choosing between prevention and treatment can be very complicated. Many prevention programs, such as childhood vaccination, are extremely effective, but we should examine many factors, such as cost-effectiveness, discounted future returns, and various ethical issues.
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