The WHO Tobacco Framework Convention

An urgent demand for effective youth protection

by Dr med Rainer M. Kaelin*

Drugs are different from usual market goods. They are not essential to life as food, but affect the behavior of individuals and their coexistence in society. Use and importance are expressed in traditions and laws. These Correlation become currently evident in the efforts to legalise cannabis and the debate on the Tobacco Products Act.
While for cannabis a legal framework for a product is searched for that is prohibited by the Narcotics Act from being consumed, distributed or sold (illegal substance), the Tobacco Products Act seeks to regulate production and marketing of tobacco so as to minimize damage to health. In both cases, the legislator should consider all the consequences that addictive substances cause on an individual and collective level. Tobacco is extensively studied like no other substance. This article describes tobacco as a drug paradigm of the consumer society and the WHO Framework Convention on Tobacco Control in response to its social consequences as well as its claims to the future Swiss Tobacco Products Act (TabPG).

Emergence of the tobacco epidemic

Tobacco from Nicotiana Tabacum leaves (after J. Nicot, who first cultivated the plant in Europe) was unknown in Europe prior to the discovery of America. It was used by the inhabitants of North America as a medicinal substance and for the peace pipe. As pipe tobacco or as cigars, chewing – or snuff tobacco taxed since the 16th century often as a state monopoly, it was irrelevant for public health. Its role as a harmful “luxury food” began with the cigarette, which made smoking tobacco accessible to everyone. Machine cigarette manufacturing was introduced in Virginia as early as 1881, but cigarette smoking did not spread until the World Wars.
The finding that tobacco smoking is addictive and that it depends on the nicotine content,1 led to the use of more nicotine-rich Burley tobacco (Camel 1913, Lucky Strike 1916, Chesterfield 1918). The stronger irritation of the throat by the concentrated insecticide nicotine was alleviated with liquorice, honey, etc. and menthol (“Colds – you do not have to renounce smoking!”). Menthol is also found in small quantities in so-called non-menthol cigarettes. It suppresses the coughing stimulus, thus allowing inhalation. This leads nicotine more quickly through the circulation to the brain, as the huge surface of the alveoli and not just the oral and pharyngeal mucosa (as in smoking pipes and cigars) absorb the drug. Philip Morris biologists found in the fifties that nicotine is a volatile substance in basic smoke, which is absorbed much faster than nicotine in salt form. Therefore, ammonia was added to the tobacco blend of Marlboro. The sales figures of the new cigarette confirmed the commercial logic in Switzerland, where it was first produced in Neuchâtel since 1956 outside the United States. A basic tobacco blend also proved beneficial because the volatile nicotine is not detected by the ISO certified “smoke machine” measurement. The increased smoker mortality was studied in epidemiological studies of the fifties: In 1964, the report of the chief American doctor, the Surgeon General, showed a considerably increased death rate among smokers.
Since many studies focused on cancer-causing substances, cigarette manufacturers responded first with the filter cigarette (“we removed the harmful corrosive substances from the tobacco”) and later with the “light” or “mild” cigarette, of which advertising and promotion suggested a health benefit. This is and remains unproven. However, the notion of smokers and the general public took hold that there was a misunderstanding of a relationship between the stated level of pollutants and the actual smoke exposure of the lungs. Explanation: When a smoker changes from his usual cigarette to a “mild” cigarette, he believe to smoke less and do less harm to himself, because he feels less irritation of the throat. His blood nicotine level has hardly changed, the carbon monoxide content of his blood is even higher. This is because dependent smokers seek to maintain their usual mean blood nicotine levels, regardless of the perceived “strength” of the smoked cigarettes or their number. With less nicotine containing products they achieve this, often unconsciously, by means of hasty pulling, deeper inhalation or smoking close to the filter. More carbon monoxide is produced, which corresponds with the stronger smoke exposure of the lung. “Damage reduction” is illusory because it is derived in advertising and promotion from the nicotine and pollutant levels measured by the smoke machine. However, human smoking behaviour is mainly to exclusively determined by the nicotine needs of the addict.2
The fall of the Berlin Wall in 1989 and the globalisation of trade and finances opened new markets for the tobacco-multinationals for their more rapidly addictive products, compared to those common in Eastern Europe, the Middle East and Asia. As a result, the tobacco epidemic also spread in these parts of the world and in Africa. The global tobacco epidemic proves that the public health problem tobacco, much more than that of the plant, is determined by industry behavior. First, it had optimized nicotine intake by its customers with the industrially produced cigarette. Second, it managed to conceal the toxicity and drug nature of its products through advertising, promotion, public relations and the use of scientists, the media, business associations, parliamentarians and public opinion in order to prevent legal tobacco control.

The WHO Tobacco Framework Convention

The first project for a Tobacco Framework Convention was launched by the WHO General Assembly in 1996 and unanimously approved by its 192 member states (including Switzerland). The tobacco industry advocated “reasonable” passive smoking regulations, the ban on sales and market restrictions for the target audience of minors, but opposed increased tobacco taxes and restrictions on the free market and called for voluntary measures.
The WHO Framework Convention on Tobacco Control was signed between 2003 and 2004 by 168 WHO (resp. UN) member countries and the European Union. Today, it brings together 181 members and covers over 90% of the world’s population. It is one of the most supported conventions in United Nations history. The following countries have indeed signed but not legally ratified it: Argentina, Cuba, Haiti, Morocco, Switzerland and the USA. These six countries are therefore not yet obliged to comply with the prevention requirements of the Tobacco Framework Convention …
The follow-up conferences (COP, Conference of Parties) to this Convention – the next one will take place in Geneva in October 2018 – will update the guidelines on certain topics. Switzerland’s former Minister of Health, Federal Councillor Pascal Couchepin of the Liberal Democratic Party, signed the Convention in 2004, thereby expressing the Confederation’s support for its objectives and for international cooperation. Ratification has been on Swiss Parliament’s agenda for almost 15 years, but it has not been addressed yet.

Dishonest addiction and tobacco prevention

The 2004 WHO Framework Convention created a clear frontline between government prevention and tobacco industry: smoking rates of those countries implementing its measures have made considerable progress.4
With promoting electronic cigarette (e-cigarette) as a stop smoking aid, and devices that “heat but do not burn” tobacco (“vaporizers”, etc.), industry today claims to be a partner in tobacco prevention.5 These products, as well as snus (oral tobacco approved exclusively in Sweden), are said to be “less harmful than tobacco smoking” and should help smokers who cannot stop smoking. Therefore they are required to be less regulated.
This is also expressed in a paradoxical media release of the Swiss Association on Addiction (Fachverband Sucht), recognising e-cigarettes as an “instrument of harm reduction”.6 In doing so, it plays down the drug nicotine.
However, the term “harm reduction” is misleading. It may be true, yet it is unproven, that a habitual smoker who gives up tobacco cigarettes and completely satisfies his nicotine consumption with “alternative products” might suffer less harm. However, it is not plausible that this should lead to collective “harm reduction”, i.e. lower smoking rates. It has been shown that e-cigarettes are preparing particularly young people for nicotine and tobacco addiction.7,8,9 As with other drugs, young consumers will sooner or later resort to the “best” way of consuming nicotine – that is to say to tobacco cigarettes.
It has already been observed that e-cigarette users are becoming double users who use the cheap gadget to cover their daily nicotine demand, while at the same time indulging in “pleasure cigarettes” (where they are mistaken regarding harm reduction). The vision of Prof. Etter10 of the Institute of Global Health in Geneva has proved to be an error.11 He and his entourage are convinced that smokers are turning away from conventional cigarettes and that this shift in the market will reduce cigarette consumption and smoking quotas. This argument overlooks the fact that the business model of both cigarette manufacturers and “alternative products” is based on nicotine addiction of the customers. Addiction is most easily anchored in the developing brains of young people. Industry has always practised this successfully with sophisticated advertising and promotion,12 in order to ensure regular consumption of young nicotine addicts and thus profit. The assertion that these products are aimed exclusively at adult smokers cannot be meant honestly. This would mean drying-out the market for alternative products and tobacco after the current generation of smokers. Nicotine dealers responsible for the tobacco epidemic are not credible authors of this message!
The previous drafts of the Federal Tobacco Products Act (TabPG) convey a similar message. In the current second draft of the TabPG, a majority of parliamentarians urges the Federal Office of Public Health to anchor the protection of minors, but to abolish advertising bans, that is an absurd contradiction. In addition, in May 2018, a judgement of the Federal Administrative Court for Minors (Bundesverwaltungsgericht für minderjährige Kinder und Jugendliche) made possible a de facto “legalisation” of previously banned nicotine-containing e-liquids for e-cigarettes. Free market prevailed over health.

Conclusions

For the legislator, it follows that structural measures in addiction and tobacco prevention must be the expression of political will. Health consequences of addiction must be analysed on the basis of scientifically recorded causal relationships.
The WHO Framework Convention on Tobacco Control considers public health problems caused by tobacco as an epidemic caused by industry based on nicotine addiction of its customers. Therefore, it is not the legally required maximum limits of ingredients and other specific measures that are important, but the barriers that are imposed on the industry for marketing of all nicotine products. In Switzerland, no provisions of the Convention to curb supply and demand have been effectively implemented yet.
The second preliminary draft of the Federal Act on Tobacco Products, currently before the Federal Parliament, proves once again the will of a majority of politicians to promote the interests of industry instead of implementing the protection of minors.13 A comprehensive ban on advertising, promotion and sponsoring, including “alternative products”, is the indispensable condition for achieving notable success in both tobacco and addiction prevention, since young people are the target audience of a wide range of drug traffickers. The findings expressed in the WHO Framework Convention are also relevant to the political debate on the legalisation of cannabis to prevent that the pursuit of profit from commercialisation of this weed – as in the case of tobacco plants – escalates in a public health problem accepted by the liberal legislator.14     •

* Dr med. R. M. Kaelin, FMH specialist in internal medicine and pneumology, in independent practice until 2015. Former Vice-President of the Lungenliga Schweiz and the Lungenliga Waadt, Vice-President of OxyRomandie/OxySchweiz (an organisation which advocates tobacco product legislation in Switzerland, which protects young people with a comprehensive ban on advertising, promotion and sponsorship of tobacco products and which aims at Switzerland ratifying the WHO Framework Convention).

1    Kaelin, R. M. Damage reduction through “less harmful” products? SAeZ; 98 (28-29): 915-917
2     Benowitz, N.L .; Hall S.M .; Herning R.I. et al. Smokers of low yield cigarettes do not consume less nicotine. N. Engl. J. Med. 1983; 309 (3): 139-42
3    The assessment of the data material can be found in the “Reports of the Surgeon General. The Health Consequences of Smoking”: 1964 mortality of tobacco smoking; 1966 nicotine and tar content; 1981 The Changing cigarette (pollutant content); 1988 Nicotine Addiction
4    GBD 2015 Tobacco Collaborators: Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: a systematic analysis of the Global Burden of Disease Study 2015. the lancet online, April 5, 2015. dx.doi.org/10 -1016 / 50140-6736 (17) 30819-x
5    Kaelin, R.M .; Barben, J .; Schuurmans, M. Electronic cigarettes, e-shishas and “heat but not burn devices”. Swiss med. Forum 2017; 17 (5): 113-119
6    trade association addiction. Media release “Evaporation instead of burning - Federation of Addiction Experts calls for a change of course in Swiss tobacco policy” from 22.11.2017
7    E-Cigarette Use among Youth and Young Adults. A report from the Surgeon General. US Dept. Health Human Services 2016
8    Wang, T.W .; Gentzke, A .; Shaparova, S. et. al. Tobacco product use among middle and high school students - United States 2011-2017. MMWR. Wkly Rep. 2018; 67 (22): 629-633
9    Schröder, T. The controversial e-cigarette Juul now wants to conquer Europe. NZZ am Sonntag from 7.7.2018.
10    Etter, J.F. La vérité sur la cigarette électronique. Fayard, Paris 2013.
11    Beard, E .; Brown J .; Michie S .; West R. Is prevalence of e-cigarette and nicotine replacement therapy use among smokers associated with average cigarette consumption in England? A time series analysis. BMJ Open 2018; 8: e0116046. First published June 19, 2018. bmjopen.bmj.com/content/8/6/e016046.
12    Kaelin, R. M. Protection of minors without advertising bans? SAeZ 2017; 98 (41): 1347-1349
13    Kaelin, R. M .; Niedermann, R. Second draft to the tobacco product law: fraud! SAeZ 2018; 89 (24): 811-813
14    Kurosh, Yazdi. The cannabis lie. ISBN 978-3-862-65-633-2. Schwarzkopf and Schwarzkopf 2017

WHO tobacco framework convention Containment of tobacco use, guiding principles

WHO framework Convention on Tobacco Control (WHO FCTC)(www.who.int/fctc)

  • It confirms the right of all people to health and is based on scientific evidence.3
  • The relation of demand and supply of the substance is integrated in the strategy and thus realises a change of paradigm.
  • It confirms that tobacco products are developed to generate dependency and that liberalisation of the world trade, international financing, global marketing and sponsoring are causing the tobacco epidemic.
  • It requires all member states to protect their laws from infiltration by commercial interests and from conflicts of interest. (Art. 5.3)
  • It requires the status to cooperate with the “civil society” (academic institutions, non–governmental organisations, e.g.), except with the tobacco industry and its allies.

Reduction of demand:

  • Gradual price increases of more than 10% and tobacco taxes that account for more than 75% of the selling price do reduce numbers of smokers and prevent young people from starting to smoke.
  • Bans on smoking in public places and at work places are reducing opportunities to smoke.
  • Comprehensive bans on advertising, promotions and sponsoring for tobacco and nicotine products.
  • Regulating substances and additives that make smoking products attractive to young people.
  • Package regulations and warnings, information for the public.
  • Programmes for smokers to overcome the nicotine addiction.

Reduction of supply:

  • Preventing illegal trade.
  • Ban to buy and sell to or from minors.
  • Support for farmers who give up tobacco growing.

Juvenile e-cigarette users consume also canabis three times more likely later

jpv. In recent weeks Swiss media reported that the American start-up Juul wants to tackle the Swiss market. Juul is a new type of electronic cigarette (e-cigarette), which is already a marketing success in the US. The company was currently valued at $ 15 billions and had expanded within 8 months in the US market share from 30 to 70 per cent.
The e-cigarette is advertised by the company Pax Labs as an alternative to tobacco cigarettes and as a means to get away from smoking totally. Unlike e-cigarettes with liquids, Juul works with nicotine salt. In the US, Pax Labs sells nicotine with 5 per cent. In the EU and Switzerland, the dose would have to be about half to allow the sale.
Markus Wildermuth from the Blue Cross Bern-Solothurn-Freiburg is alarmed. “Juul must not be sold in Switzerland until it is clear what nicotine salts cause in the body.“ Because according to a new study, published in the journal “Tobacco Control“, vapours don’t only inhale the same amount of nicotine with Juul as in a tobacco cigarette, there is also more cotinine – a degradation product of nicotine – in their urine. In addition,  the steam of Juul is scratching less  than regular liquids, says Wildermuth. “Instead of an alternative Juul is a product that leads to even higher nicotine consumption.“
According to a study published in the journal JAMA Pediatrics on 17 September 2018, with over 20,000 students, 12.4 per cent of high school students and 4.5 per cent of younger high school students in the US have vapoured at least once in their live cannabis in an e-cigarette (also known as “vaping“).
The study used data from the “National Youth Tobacco Survey 2016“. In recent years tobacco vaping has gained popularity among young people. Since some e-cigarettes are small enough to fit in the palm of your hand and some are odorless, they can be used discreetly – sometimes on the school grounds. Further studies have linked tobacco vaping with later increased cannabis use.
According to a study recently published in the medical journal Pediatrics, young people who use e-cigarettes or shisha are more than three times more likely to later use cannabis. Researchers surveyed about 2,600 students, whether they had already used e-cigarettes, vaporisers or hookahs. Three years later, they were asked again concerning their cannabis consume. It was found e.g. that students who used e-cigarettes in the first survey were more likely to consume cannabis in the second survey than those who did not use any e-cigarettes.

Sources: “20 Minuten” from 21.9.18;
www.getsmartaboutdrugs.gov/new-statistics/2018/08/06, https://jamanetwork.com/journals/jamapediatrics/fullarticle/2593707 
http://pediatrics.aappublications.org/content/pediatrics/early/2018/08/02/peds.2017-3616.full.pdf 

(Translation Current Concerns)

Investors see legalisation of Cannabis as a billion-dollar business

ds. The article “Coca-Cola bets on cannabis” from 19 September in the business section of the “Neue Zürcher Zeitung” confirms that the legalisation of cannabis promises a big, even a very big business. Under the subheading “Enormous growth prospect” it says: “Many investors also see the legalisation of trading in marijuana products as an opportunity worth billions. Global expenses for legal cannabis are expected to increase by 230% in just five years, from 9.5 billion US dollars at the end of 2017 to 32 billion US dollars in 2022. BDS Analytics’ latest report estimates that the global legal marijuana market could be worth 57 billion US dollars by 2027. Expenses on cannabis-based pharmaceuticals in the United States are expected to increase by 50% annually until 2030.”