Anti-tobacco advocate Professor Dr Judith Longstaff Mackay has been identified as ‘one of the three most dangerous people in the world’ by the industry. She was instrumental in developing the World Health Organisation’s Framework Convention on Tobacco Control. In her recent visit to Malaysia, she shares her experience campaigning against tobacco in Asia since 1984.
“I HAVE been described as a ‘psychotic human garbage, a gibbering Satan, an insane psychotic, power-lusting piece of meat, Hitler and a nanny’ and they (the tobacco industry allies) threatened to destroy me. But such threats and offensive words never once diverted me from my cause,” says Professor Dr Judith Longstaff Mackay.
Dr Mackay, 73, wears many hats. The World Health Organisation (WHO) senior policy adviser is also senior adviser to Vital Strategies, part of the Bloomberg Initiative to Reduce Tobacco and director of the Asian Consultancy on Tobacco Control.
Her recent visit was part of her capacity as a visiting professor at the University Malaya Centre of Addiction Sciences.
A recipient of British Medical Journal Lifetime Achievement Award (2009) and a Special Award for Outstanding Contribution on Tobacco Control (2014), she has published 200 papers, and addressed over 460 conferences on tobacco control.
Dr Mackay has received many international awards in recognition of her contribution on tobacco control. She was selected as one of Time’s 60 Asian Heroes (2006) and of Time’s 100 World’s Most Influential People (2007).
Question: Born in Britain, you moved to Hong Kong in 1967 after earning a medical degree from the University of Edinburgh in 1966. What led to your resignation as a physician in 1984, and then becoming a leading campaigner and advocate for tobacco control for the last 30 years?
Answer: I had a complete career change from cure to prevention and there were three main reasons for making the shift.
First, when I was working in a hospital in Hong Kong, we had a maxim on our male medical wards that every person we admitted was a smoker with tobacco illnesses, like heart diseases, cancer and chronic chest problems, which were often too late and too advanced to be cured.
I realised we had to go a step “higher upstream” to prevent this rather than merely providing the ambulance services at the end-stage.
I came to feel that hospital medicine was important but it works like a band-aid in comparison with prevention.
You may be able to save hundreds of lives in a lifetime in hospital medicine, but millions of lives could be saved if you work in prevention. It is a completely different ball game, and yet the money, prestige and attention all go to curative medicine; and that is similar around the world.
Second, was the realisation that although women’s health those days was defined very gynaecologically, more women were being killed by tobacco than by every method of contraception combined. I was particularly concerned that the tobacco industry was enticing women with promises of beauty, fame, emancipation and freedom.
The third reason was that the tobacco industry felt Asia was theirs for the taking.
They said it themselves — when asked about their future in the 1980s, “What do we want? We want Asia”.
Q: Why did the tobacco industry had their eyes set on Asia?
A: They wanted the huge populations and the large number of men already smoking who could be persuaded to smoke their brands of cigarettes.
They galloped into Asia with the dream of converting the 60 per cent of men who smoked local cigarettes to switch to international brands, and the second dream of persuading Asian women to start smoking. If this happened, their markets would be enormous.
It would not matter if every smoker in Britain stopped smoking tomorrow if they could capture the massive Asian markets.
Also, Asia was becoming more affluent, so, it was easier for people to afford cigarettes.
Thirdly, when I wrote an article in the South China Morning Post on banning cigarette advertising, a tobacco giant came down on me and labelled me as “entirely unrepresentative and unaccountable”.
The tobacco industry claimed that they were the best source of information on tobacco and they even said it has not been proven that “illness was actually caused by smoking”.
I was so outraged that it was just one of those tipping points in life in 1984. Everything came together and I realised that I really had to work on prevention rather than cure.
Ever since, I have been working principally with governments on the policy level to try and get the tax and the laws in place in tobacco control.
Q: You are known as one of the three most dangerous people in the world by the tobacco industry. What do you have to say about this?
A: Well yes, I’m proud of that. The reason that I got that title was essentially location. I happen to be in Asia and the tobacco companies wanted Asia. They saw this region as their future, but I set about thwarting their goals.
I went early on to countries like China, Indonesia, Malaysia, Mongolia, Vietnam and Cambodia and more recently to North Korea upon learning that British American Tobacco had gone into the country to get laws in place.
Q: In campaigning against tobacco use, what are some of the challenges you have faced?
A: I have had many problems, and was subjected to verbal abuse and even had death threats from allies of the tobacco industry.
Twice, I was threatened by the tobacco industry publicly, saying they would take me to court.
Nothing came of it, so it was either an attempt to intimidate me or to cast doubt on my credibility in the minds of the public.
In a television interview in South Africa, I openly said “I’m not a suicidal type, and if I were to be found knocked down by a bus, you need to find out if the tobacco industry is behind it before you look anywhere else.” And the industry was apparently furious with me for saying that.
However, their tactic now is not so much to attack people individually, but to threaten governments.
They threaten them under Constitutional Law on the rights of their products to advertise, and on freedom of speech and they attack them under trade treaties.
This is intimidating to governments and it can cost anything up to US$50 million (RM214 million) to fight these threats.
Q: You were one of the key persons in formulating the Framework Convention on Tobacco Control (FCTC), the first international treaty on public health. Malaysia is currently drafting the Control of Tobacco and Smoking Bill after lobbying for it since 2004 and they have sought your expertise. What do you have to say about this?
A: If you look at Malaysia and Hong Kong, many of the things that these two jurisdictions have done in the last 30 years are similar, yet Hong Kong has managed to half its male smoking rate.
Hong Kong is down to 10 per cent smokers now, whereas prevalence rates in Malaysia have not really decreased (at around 22.8 per cent). I understand it is not something that can be done overnight.
But the fact that the prevalence has not decreased is either because the excise tax imposed on cigarettes is not high enough, or that the laws that have been passed are not being enforced. In the case of the tobacco bill, the tobacco industry has been an unseen hand behind the scenes.
Q: The Health Ministry plans to increase prices of cigarettes from RM17 to RM21.50 in the near future to deter people from smoking. Several industry players were quick to say that increasing the tax would only lead to increased sales of illicit cigarettes. Is this true? What is the link between the increase in excise tax and contraband cigarettes?
A: There is zero truth in this. This sounds to me suspiciously just like what the tobacco industry would say. Economists, tax, finance and customs officials know, or they should know, that putting up a tobacco tax is not related to any increase in smuggling.
Our Customs chief in Hong Kong, for example, had said quite categorically there is no relationship between the amount of tax that is put in place and smuggling, and that is the position of the WHO too. But the tobacco industry keeps repeating it so often that some governments have come to believe it.
This is one of their tactics. A United States-based non-governmental organisation (NGO) has been going around the world, saying “don’t put up the tax, otherwise, there will be a rise in illicit cigarettes”. What many governments do not realise is that it is funded by the tobacco industry.
Q: WHO proposes that the tax imposed on cigarettes should be at least 75 per cent of the retail price. How efficient would this be in reducing smoking prevalence particularly among Malaysia’s young as compared with other measures, such as school education programmes?
A: Ten experts from around the world were present at a conference held in Hong Kong and, each speaker was asked “If you have one thing to do in tobacco control, what would that be?” and every single one said “tax”. This is because higher prices make cigarettes unaffordable to young people.
Taxation is the most effective approach to controlling the spread of tobacco. Creating smoke-free areas is the second measure, followed by things like advertising bans and smoking cessation.
Some people say health education in schools is crucial. Certainly, everybody likes health education, but it has not been proven effective in bringing down the prevalence of youth smoking.
And you can tell it is not effective because the tobacco industry does not oppose it. They oppose tax increases, plain packaging and smoke-free areas. And because the tobacco industry fights them, we know these are the measures that work.
Q: What needs to be done to improve our health education programmes at schools?
A: School health promotion programmes do not work because traditionally they say that if you smoke, you will get cancer when you are 60 years or heart attack when you are 70 years. If you are only a 11-year-old child, it is totally meaningless.
We need to do much more to revitalise and revamp health promotion and health education. Smoking and non-smoking youth have, in fact, the same level of health knowledge about the harms of smoking. The difference between the two groups is whether they think smoking is cool or a dirty expensive habit.
We have got to make it attractive to be a non-smoker in the teenage years.
According to Professor Dr Judith Longstaff Mackay, creating smoke-free areas is an effective approach to controlling the spread of tobacco. File pix by Muhammad Hatim Ab Manan
Q: The Control of Tobacco and Smoking Bill currently being drafted would see the minimum age for buying cigarettes raised to 21 years old, ban on displaying tobacco products and making it illegal to smoke in vehicles with children inside, among others. How effective would this be in tackling smoking prevalence?
A: (People aged) 8 to 23 years is a vulnerable period. If you can stop children from smoking at this age, they are less likely to smoke. Whereas before that, they do not have the kind of mature judgment to analyse what it will mean to actually smoke.
The tobacco industry is very interested in youth and young adults because one has to only smoke 100 cigarettes and he or she will become lifelong smokers. It is so addictive.
Q: Besides health effects, what are the other impacts of cigarette smoking to the country and its people?
A: Two out of every three smokers die from cigarette smoking, so, you are losing skilled workers. One in every three fires in the world is caused by careless smoking.
There is also loss of productivity. Smokers go out for seven minutes to smoke. So, that’s seven minutes every time they smoke. Smokers are sicker and die on average a decade before non-smokers, so families lose their bread-winner.
There are medical and health costs. There is smoke damage to buildings and fabric.
And then there is a massive cost of cleaning up all the litter, billions of cigarette ends, packets, matches and lighters that are discarded every day in the world.
The tobacco industry claims that tobacco control would harm workers and farmers. This is not true. We have got so many projects now, including right in the heart of tobacco-growing in China showing that if farmers grow alternative crops they actually earn more.
The second fallacy is that if restaurants go smoke-free, they would lose revenue. Nowhere in the world has that happened. The revenue, including in Hong Kong and California, where they have introduced smoke-free policies, has gone up and not down.
Another fallacy is the government would lose money if it puts up the tax.
This does not happen. Some smokers will still pay more for cigarettes, so the revenue goes up. The number of smokers will come down particularly among the young and the poor.
There are so many economic fallacies that some non-governmental organisations propagate. Sometimes, governments almost innocently believe these economic arguments.
Q: If the situation is so dire, why can’t countries impose a blanket ban on cigarettes?
A: No country has put a blanket ban on cigarettes. Authorities have learnt from the prohibition of alcohol in the United States (1920-1933), for example, that it leads to much bigger implications particularly with crime and corruption cases.
So, the idea is to slowly push tobacco use back, so that the reduction is genuine and it is done throughout the community. This is what every government is really trying to do rather than actually ban it.
Q: Malaysia aims to be smoke-free (the End Game of Tobacco) by 2045. Are we moving in the right direction?
A: I strongly commend Malaysia for the foresight in establishing the 2045 goal and targets; few countries have yet to do this.
Recently the prevalence of male smokers has begun to decrease.
It is going to require a major commitment by the government and a huge effort by academia as well as non-governmental organisations in achieving this goal.
The Health Ministry has worked out a year-by-year plan of reducing prevalence up to 2045. It has developed a roadmap and has filled in what needs to be done each year to achieve the goal.
But it is not a quick process: if a country reduces its prevalence by one per cent a year, it is doing quite well.
So, it’s possible for Malaysia, but it will be challenging.