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Attitudes towards smoking regulation in Italy
CORRESPONDENCE
US pressure on lessdeveloped countries Sir—What makes the conflict between the US and Brazil reported in your Feb 10 news item1 noteworthy is the fact that Brazil is trying to resist the pressure. Thailand has been subjected to trade pressure from the US government for increased intellectual property protection of pharmaceuticals since 1985.2 By contrast with Brazil, the Thai government has not felt able to resist or undo the damage. Thai patent law was amended to include pharmaceutical product protection in 1992, when Thailand came under threats of trade sanctions by the US Trade Representative after a complaint by the US Pharmaceutical Manufacturers Association, underline if present. The Thai Safety Monitoring Programme (SMP), a postmarketing surveillance system, has been abused to provide protection and thereby monopolies to drug companies. In 1989, an interim measure was applied to allow 2 years monopoly for all new drugs entering under the SMP, which was extended to 5–6 years in 1993 after further US pressure. Thailand was not required to provide patent protection before 2000 and is not required to provide exclusive marketing rights for non-patented drugs at all. The SMP system has led to substantial delay in generic availability for drugs such as antiretrovirals, and many others, although none of these drugs are patented in Thailand. Some drugs have completed the SMP and have become affordable thanks to generic production. Such falls in price can mean life or death in a country still in the aftermath of the economic crisis and the highest number of AIDS deaths in Asia. Thailand has done little to undo the damage of US pressure. The SMP was revised only in January, 2001: market exclusivity was removed and safety monitoring strengthened. However, market exclusivity is abolished only for drugs already covered by the 1992 patent law, and is preserved for drugs patented abroad between 1986 and 1991 that the US government has sought to protect. WHO and UNAIDS had supported a more decisive amendment but Thailand did not question the concessions made under US pressure in 1992. Another disturbing experience was the failed attempt to issue a compulsory licence for the formulation patent of didanosine in early 2000. Despite the US government’s promise
THE LANCET • Vol 358 • July 21, 2001
in December, 1999, for a more flexible trade and patent policy for medicines, they continued to warn the Thai government against the use of compulsory licence. Eventually, demonstrations in Bangkok and in the US forced them to relent. But the initial warnings were hard to forget and the Ministry of Public Health rejected activist calls for compulsory licence. Solutions must come from both sides. The USA and other western governments should commit to a moratorium on World Trade Organisation disputes that affect access to medicines. Less-developed countries should follow the example of Brazil in resisting the pressure and make maximum use of available safeguards to protect the health of their people. *Tido von Schoen-Angerer, Jiraporn Limpananont *Médecins sans Frontières, 311 Ladphrao soi 101, Bangkok 10240, Thailand; and Faculty of Pharmaceutical Sciences, Chulalongkorn University, Thailand (e-mail: [email protected]) 1
2
Ahmad K. Brazil and USA at loggerheads over production of generic antiretrovirals. Lancet 2001; 357: 453. Wilson D, Cawthorne P, Ford N, Aongsonwang S. Global trade and access to medicines: AIDS treatments in Thailand. Lancet 1999; 354: 1893–95.
Attitudes towards smoking regulation in Italy Sir—Despite countless proposals in the past few decades1 a comprehensive tobacco policy, such as those adopted in Scandinavian countries since the 1970s or in France in 1992,2–4 is still lacking in Italy. The latest proposal, made in 2000, by the Minister of Health, Umberto Veronesi, was not approved in past legislature, and was consequently dismissed. In April, 2001, a survey was done by the Istituto Doxa, the Italian branch of the Gallup International Association, of attitudes towards smoking regulation, in the general Italian population in 1009 adults (484 men, Question
Strongly in favour
Separate smoking areas 60·7% in cafés, restaurants and other areas open to public, and smoking ban in their absence Endorsement of smoking 85·2% ban in public administration (post offices, schools, hospitals) Adoption of smoking ban in 58·4% private working places (offices, factories)
525 women) aged 15 years or older. Respondents were representative of the general Italian population for age, sex, geographic area, habitat, education, and working status. Every question had a structured, four-item score (strongly in favour to strongly against). The main findings are given in the table. With reference to cafés, restaurant, and other places open to the public, more than 83% of adult Italians were in favour, moderately or strongly, of separate smoking areas, and of a total ban of smoking in the absence of such separation. Smoking is banned in all closed areas of the public administration in Italy, but the law is not adequately endorsed. Still, more than 95% of respondents were in favour of endorsement. Finally, about 85% of respondents, slightly more women than men, were in favour of a total smoking ban in private working places. In April 2001, 29% of adult Italians (36% men, 24% women) described themselves as current smokers. Thus, non-smokers and more than 50% of smokers would support a comprehensive tobacco regulation in Italy. Public opinion cannot, therefore, be given as a reason for further delaying the adoption of such a policy. *Carlo La Vecchia, Silvio Garattini, Paolo Colombo, Vilma Scarpino *Istituto di Ricerche Farmacologiche “Mario Negri”, Via Eritrea 62, 20157 Milan, Italy; Istituto di Statistica Medica e Biometria, Università degli Studi di Milano, Milan; and Istituto DOXA, Gallup International Association, Milan (e-mail: [email protected]) 1
2
3
4
La Vecchia C, Garattini S. Italy: attitudes to legislation on restriction of smoking. Lancet 1987; 1: 1310. Boyle P. Tobacco and cancer, the European perspective. Ann Oncol 1995; 5: 435–37. Gray N, Boyle P. The regulation of tobacco and tobacco smoke. Ann Oncol 2000; 11: 909–14. La Vecchia C, Levi F, Franceschi S. Epidemiology of cancer with a focus on Europe. J Epidemiol Biostat 2000; 5: 31–47.
Moderately in favour
Moderately aganist
Strongly aganist
No opinion
22·6%
4·4%
11·3%
1·0%
11·9%
1·5%
1·1%
0·2%
26·1%
8·4%
4·3%
2·8%
Responses to smoking regulation survey
245
For personal use. Only reproduce with permission from The Lancet Publishing Group.
US pressure on lessdeveloped countries Sir—What makes the conflict between the US and Brazil reported in your Feb 10 news item1 noteworthy is the fact that Brazil is trying to resist the pressure. Thailand has been subjected to trade pressure from the US government for increased intellectual property protection of pharmaceuticals since 1985.2 By contrast with Brazil, the Thai government has not felt able to resist or undo the damage. Thai patent law was amended to include pharmaceutical product protection in 1992, when Thailand came under threats of trade sanctions by the US Trade Representative after a complaint by the US Pharmaceutical Manufacturers Association, underline if present. The Thai Safety Monitoring Programme (SMP), a postmarketing surveillance system, has been abused to provide protection and thereby monopolies to drug companies. In 1989, an interim measure was applied to allow 2 years monopoly for all new drugs entering under the SMP, which was extended to 5–6 years in 1993 after further US pressure. Thailand was not required to provide patent protection before 2000 and is not required to provide exclusive marketing rights for non-patented drugs at all. The SMP system has led to substantial delay in generic availability for drugs such as antiretrovirals, and many others, although none of these drugs are patented in Thailand. Some drugs have completed the SMP and have become affordable thanks to generic production. Such falls in price can mean life or death in a country still in the aftermath of the economic crisis and the highest number of AIDS deaths in Asia. Thailand has done little to undo the damage of US pressure. The SMP was revised only in January, 2001: market exclusivity was removed and safety monitoring strengthened. However, market exclusivity is abolished only for drugs already covered by the 1992 patent law, and is preserved for drugs patented abroad between 1986 and 1991 that the US government has sought to protect. WHO and UNAIDS had supported a more decisive amendment but Thailand did not question the concessions made under US pressure in 1992. Another disturbing experience was the failed attempt to issue a compulsory licence for the formulation patent of didanosine in early 2000. Despite the US government’s promise
THE LANCET • Vol 358 • July 21, 2001
in December, 1999, for a more flexible trade and patent policy for medicines, they continued to warn the Thai government against the use of compulsory licence. Eventually, demonstrations in Bangkok and in the US forced them to relent. But the initial warnings were hard to forget and the Ministry of Public Health rejected activist calls for compulsory licence. Solutions must come from both sides. The USA and other western governments should commit to a moratorium on World Trade Organisation disputes that affect access to medicines. Less-developed countries should follow the example of Brazil in resisting the pressure and make maximum use of available safeguards to protect the health of their people. *Tido von Schoen-Angerer, Jiraporn Limpananont *Médecins sans Frontières, 311 Ladphrao soi 101, Bangkok 10240, Thailand; and Faculty of Pharmaceutical Sciences, Chulalongkorn University, Thailand (e-mail: [email protected]) 1
2
Ahmad K. Brazil and USA at loggerheads over production of generic antiretrovirals. Lancet 2001; 357: 453. Wilson D, Cawthorne P, Ford N, Aongsonwang S. Global trade and access to medicines: AIDS treatments in Thailand. Lancet 1999; 354: 1893–95.
Attitudes towards smoking regulation in Italy Sir—Despite countless proposals in the past few decades1 a comprehensive tobacco policy, such as those adopted in Scandinavian countries since the 1970s or in France in 1992,2–4 is still lacking in Italy. The latest proposal, made in 2000, by the Minister of Health, Umberto Veronesi, was not approved in past legislature, and was consequently dismissed. In April, 2001, a survey was done by the Istituto Doxa, the Italian branch of the Gallup International Association, of attitudes towards smoking regulation, in the general Italian population in 1009 adults (484 men, Question
Strongly in favour
Separate smoking areas 60·7% in cafés, restaurants and other areas open to public, and smoking ban in their absence Endorsement of smoking 85·2% ban in public administration (post offices, schools, hospitals) Adoption of smoking ban in 58·4% private working places (offices, factories)
525 women) aged 15 years or older. Respondents were representative of the general Italian population for age, sex, geographic area, habitat, education, and working status. Every question had a structured, four-item score (strongly in favour to strongly against). The main findings are given in the table. With reference to cafés, restaurant, and other places open to the public, more than 83% of adult Italians were in favour, moderately or strongly, of separate smoking areas, and of a total ban of smoking in the absence of such separation. Smoking is banned in all closed areas of the public administration in Italy, but the law is not adequately endorsed. Still, more than 95% of respondents were in favour of endorsement. Finally, about 85% of respondents, slightly more women than men, were in favour of a total smoking ban in private working places. In April 2001, 29% of adult Italians (36% men, 24% women) described themselves as current smokers. Thus, non-smokers and more than 50% of smokers would support a comprehensive tobacco regulation in Italy. Public opinion cannot, therefore, be given as a reason for further delaying the adoption of such a policy. *Carlo La Vecchia, Silvio Garattini, Paolo Colombo, Vilma Scarpino *Istituto di Ricerche Farmacologiche “Mario Negri”, Via Eritrea 62, 20157 Milan, Italy; Istituto di Statistica Medica e Biometria, Università degli Studi di Milano, Milan; and Istituto DOXA, Gallup International Association, Milan (e-mail: [email protected]) 1
2
3
4
La Vecchia C, Garattini S. Italy: attitudes to legislation on restriction of smoking. Lancet 1987; 1: 1310. Boyle P. Tobacco and cancer, the European perspective. Ann Oncol 1995; 5: 435–37. Gray N, Boyle P. The regulation of tobacco and tobacco smoke. Ann Oncol 2000; 11: 909–14. La Vecchia C, Levi F, Franceschi S. Epidemiology of cancer with a focus on Europe. J Epidemiol Biostat 2000; 5: 31–47.
Moderately in favour
Moderately aganist
Strongly aganist
No opinion
22·6%
4·4%
11·3%
1·0%
11·9%
1·5%
1·1%
0·2%
26·1%
8·4%
4·3%
2·8%
Responses to smoking regulation survey
245
For personal use. Only reproduce with permission from The Lancet Publishing Group.