Philippe Boucher's Rendez-vous with . . . Yol Lee

Rendez-vous with . . . Yol Lee

Co-author of The tobacco's industry successful efforts to control tobacco policy making in Switzerland (January 2001) Zurich, Switzerland
The report is available on line:

By Philippe Boucher
Rendez-vous 92 Friday, March 2 , 2001

PB: Thank you Yol for accepting our rendez-vous.
May I ask you to introduce yourself?

Y L: I got involved in tobacco control while I was a Swiss clinical and research fellow in adolescent medicine at the University of California, San Francisco and a post-graduate student in public health at the University of California, Berkeley. The whole idea of writing a report on tobacco industry activities in Switzerland grew out of two necessities. The first one was the need to write a masters thesis at the School of Public Health of the University of California, Berkeley. The second one was a growing awareness that smoking didn't have to be a part of any culture, which in turn, and in combination with my experience in California, made it almost impossible for me to return to Switzerland and accept the ubiquitous secondhand smoke that ruins even the most delicious meals.

The best things in life happen by coincidence. I had invited Stan Glantz to give a talk at our division of adolescent medicine the year before I started my masters studies at Berkeley. His talk on adolescents and smoking had been truly captivating. Once I had decided I would write something about smoking in Switzerland for my masters thesis, I went to see Stan. At around that time, the WHO had gotten into contact with Stan Glantz to discuss the possibility of a cooperation in international tobacco control. Being completely new to this field: my only activity in tobacco prevention up to this moment had been restricted to encouraging smokers with coronary heart disease to stop smoking, and having been a long-time foreigner in Switzerland without any voting rights until pretty recently, the task of analyzing political-strategic documents seemed like crossing the ocean in a dinghy. But Stan's vast experience with the tobacco industry, his foresight and instinct have been extremely helpful in navigating through the various decision points in time. Also, Korean and German being my first languages, writing something extensively in English was an additional challenge.

I am presently working at the Institute of Social and Preventive Medicine, University of Zurich, Switzerland, where I am responsible as a physician epidemiologist for a national registry of myocardial infarction and unstable angina (40%), for the analysis and publication of data from a nation-wide health promotion campaign at the worksite (20%), and I also work as a physician at a private call center and internet company in Basel, Switzerland, called Medgate (20%). I try to continue with some tobacco-related work, currently through networking (Swiss media, NGO's, the Federal Office of Public Health, and the WHO) and writing letters to the editors of newspapers in response to tobacco-related articles during the rest of my time.

Q1. It is the first time the Institute for Health Policy Studies publishes a report about tobacco control outside of the US. It is mentioned that the World Health 0rganization requested this research. Why? Are there plans for similar reports about other countries?

Y L: To my knowledge, it is the first time the Institute for Health Policy Studies publishes a report about tobacco control outside of the US. However, the person who would know best is Stan Glantz. Many people in Switzerland feel that the litigation practice in the US is way too exaggerated. This attitude is mirrored in the Swiss laws that make it next to impossible to sue a company for a faulty product. This easily creates the situation where the baby is thrown out with the bath water. Others feel that their case is unique and therefore different from the US case. This is one of the main points we wanted to stress in our report, that people need to realize the global character of the strategies that have been, and are still being, used successfully by the tobacco industry all over the world in order to influence tobacco policy to their favor. Following the idea that "all politics is local", it seems to be a logical next step to analyze country-specific documents. I do believe that there will be similar reports about other countries, such as the recently published report on the middle east and the GCC countries (voice of truth vol. 1:, but I do knot know about WHO's priorities.

Q2. You mention the second five year tobacco control program planned by the Federal Government (2000/2005). How is it different from the previous 5 year program that according to you was underfunded and ignored the role played by the industry?

Y L: There are many differences in this new 5-year program that was elaborated again by the Swiss Federal Office of Public Health. The first 5-year tobacco prevention program had initially postulated 8 major strategies that were supposed to be followed. That ambitious target was soon reduced to 3 strategies under the financial restriction. It included the areas of primary prevention (fairly general), secondhand smoke, and smoking cessation. As the Office of Public Health later admitted, it had focused on traditional strategies, such as information campaigns, whereas legislative measures had been neglected. One of the best parts of the program was the evaluation of it, which clearly helped to improve the quality of the 2001-2005 program. This new program has 6 major target areas, including the development of a national (coherent) tobacco prevention policy, legislative measures that contain 5 specific target areas, including tax increases, advertising restrictions (not a complete ban!), and prohibition of sales to minors. The program also aims at increased international cooperation, such as active cooperation with the WHO in its Framework Convention. A central knowledge bank that also incorporates experiences made in other countries will be created in an active dialog with tobacco prevention experts from other countries. Finally, a quality assurance system will be developed in order to document and influence the quality of structure, process, and outcome. In doing so, the role of the Federal Office of Public Health and of the NGO's, has been defined much more clearly. Even though the draft document of the tobacco prevention program, published and distributed for commentaries (the synthesis of the commentaries will be available by March, and the government will most likely take a final position by the end of April), mentions the role of the tobacco industry, active uncovering of tobacco industry's role and dissemination of this information does not figure among the 6 major target areas of the tobacco prevention program, presumably due to its politically sensitive nature. Having said that, I am not too optimistic about the potential of the program to cover all of its major topic areas during the coming 5 years, as the money allocated to this whole effort is hardly going to be enough (2.5 Mio CHF per year until now, which allowed the office to cover only three areas partly; most likely 4-5 Mio CHF per year for the next 5 years). The fact that one of the target areas is raising more money for tobacco prevention has actually been added doesn't necessarily help. The awareness of the lack of finances has not been as acute as the document might make us believe. One possible solution is the creation of a foundation from the tobacco taxes that would be allocated exclusively to tobacco prevention, and this is mentioned in the draft program.

Q3. Among your conclusions you state that "most public health advocates underestimate the power and driving forces behind the tobacco industry and only a few of them have confronted the industry directly". Couldn't that be just the opposite?
It has been my experience (and Stan also saw that many times in the US) that many health advocates leaders (or so they claim) are very afraid to confront the industry because they know its power. They don't underestimate the industry they rather overestimate it and their very much fear a confrontational approach.
From what you saw in Switzerland, can you foresee the coming of more combative health advocates? What could bring such a transformation within the ranks of the health community?

Y L: They may fear the obvious power given to any interest group that has much money, however, I believe that these are a minority in Switzerland, and most of them probably hold jobs that don't allow them to be politically more aggressive, because that may be hazardous to their career. The majority, I believe, has not dealt with the subtle political influences of the tobacco industry which simply were not known until recently. Also, as I mentioned above, the belief of Switzerland being a unique case does not further the learning from revelations in other countries, in particular from the US. I believe the subtle or hidden political influences make the tobacco industry truly powerful.

If anything, then it would be these revelations of unethical tobacco industry behavior and the realization of the weaknesses of a consensus democracy that may produce outrage and outspokenness in some health advocates, thereby provoking increasing voices of discontent in the public. Having said that, I don't think that a new generation of more outspoken health advocates will be so easily born. I cannot emphasize often enough the strong tradition of consensus democracy that only works under the assumption of common ethical grounds for all parties involved, which definitely is not the case with the tobacco industry.

Q4. In fact you lay a significant part of the responsibility in the triumph of the tobacco industry in Switzerland on the public health advocates: strategic choice of discretion and confidentiality instead of public confrontation, incorrect belief that Switzerland is a special case, lack of initiatives at the local level where the industry is the weakest, lack of adequate professional staff (lobbyists, PR people, public policy experts). Did the report bring any reaction from the public health community, from the main NGOs? did it get any media coverage or was it promptly buried?

Y L: Unfortunately, the report has prompted some reaction from the public health community, but mostly in the form of e-mails congratulating me. The Federal Office of Public Health has stated in interviews that the report confirmed mostly what they had known all along, and that it was helpful. But it also said that its possibilities to act politically was limited as a federal office (and this can be felt in every move it makes). Well, that office had received drafts of our report many months before the official publication, and I never got any useful feedback from them, nor from any of the public health advocates in Switzerland. However, the media echo was surprisingly broad and long-lasting. More than a month after the publication I still receive phone calls from various journalists who are preparing articles on tobacco industry-related issues.

Q5. You provide numbers about the budget spent per capita in Switzerland to promote tobacco control. About 76 cents, half from the Federal Government, half from the NGOs, for a total of about $3.2 million per year. In its best practices report the CDC provides a low and high estimate of what the tobacco control budget should be. What would your estimates be for Switzerland? what is the reality now?

Y L: The number for Switzerland would be between 45 and 144 million CHF (USD 1 ~= CHF 1.6 or 1.7) per year, including 9-27 million for media campaigns. The currently proposed amount by the government is CHF 4-5 million...

Q6. Is there anything else you would like to add?

Y L: Thanks for your efforts to introduce tobacco prevention advocates worldwide and their work to each other.

PB: Thank you Yol for taking the time to be with us today.

Rendez-vous is supported by a contract from the Robert Wood Johnson Foundation
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