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The slippery slope

| May 1, 2014

Once dismissed as scaremongering, the tobacco industry’s warning that health advocates would soon target other sectors is starting to sound prescient.

By Simon Roper

“Sugar is the new tobacco,” proclaimed a January headline in the Daily Mail, a major U.K. tabloid. The refrain echoes around the world. Type the terms tobacco and sugar together into your Internet search engine, and you’ll receive a large number of results; my query returned 60 million hits. The volume of published research on sugar and obesity grows swiftly as well, rivaling that on alcohol and tobacco. A new campaign organization, Action on Sugar, has been set up in the U.K. and the U.S. to drive awareness and promote government intervention. Ninety percent of doctors surveyed in Europe believe governments should do more.

The growing vilification of sugar suggests that, having “tamed” tobacco, public health advocates are in search of a new target. Dr. Margaret Chan, director of the World Health Organization (WHO), admitted as much when she said that, in the wake of the tobacco control movement’s success, “obesity is now the most visible epidemic that needs to be stopped.”

Despite the shift in focus, it seems unlikely that the pressure on tobacco will be eased just yet. Many developed countries are targeting smoking rates of just 5 percent, even as prevalence has proved difficult to push below 15 percent. So regulators are advocating ever-more extreme restrictions, grasping for untested measures, such as smoking bans in cars, standardized packaging and other measures that will further denormalize smoking.

But as the public health lobby widens its net, the risk that the tobacco industry has been warning about for years—that other lifestyle products would be targeted next—is starting to be realized. The same weapons used to fight tobacco will be deployed in the battle to make us healthier citizens—or, at least, less costly citizens. It used to be said that the issues raised by regulation pertained only to tobacco companies and that the “slippery slope” was a narrow ride reserved for them. It may be about to get busier and wider.

From sweet to sour

Why sugar? Just like mechanization made cigarette production easier and cheaper, and the growth in international trade carried them around the world, sugar refining and the advent of sweet drinks led to widespread consumption of sugar, not only in markets such as the U.S. but also in the developing world. The results have been dramatic: Two-thirds of Americans are now overweight; more than one-third are clinically obese. Seventeen percent of children are obese. Obesity significantly raises the risk for diabetes, heart disease, strokes and some cancers. These diseases can be expensive to treat, and governments are increasingly concerned about the drain on their resources. According to Action on Sugar, “Obesity and diabetes already cost the U.K. over £5 billion [$8.37 billion] a year. Without regulation, these costs will exceed £50 billion by 2050.”

Sugar is not the only risk factor for obesity, but some argue it is by far the most important. One influential voice is Dr. Robert Lustig, of the University of California, an expert on childhood obesity. He has been campaigning against sugar for some time and has a growing Internet following. His lecture Sugar: The bitter truth has been viewed more than 4 million times on YouTube. Lustig believes, and seeks to demonstrate through biochemistry, that fructose (the main form of sugar used in drinks) is not just high in calories; it causes much higher levels of fat in the body than glucose or other carbohydrates and should be treated as a toxin. He equates fructose with alcohol and asks why the U.S. Food and Drug Administration does not regulate it like that substance.

Increasingly alarmed, the WHO recently halved its recommended daily intake of sugar. In 2000 it adopted a plan to target non-communicable diseases, principally diabetes, cancer, COPD and heart disease. A new strategy to drive the initiative forward, the NCD Global Acton Plan 2013–2020, was adopted last year. Chan recently warned that diabetes alone was becoming a major health burden to many governments, consuming up to 15 percent of some nations’ annual budgets.

In a recent report, Credit Suisse offered this insight: “The global obesity epidemic and related nutritional issues are arguably this century’s primary social health concern. The focus on well-being has shifted from disease to diet.” For many, like Lustig, sugar and sugary drinks call for the most urgent attention.

The obesity phenomenon is not restricted to the developed world. Since World War II, the biggest winner, U.S. industry, has been hugely successful in taking its products to all corners of the world—and none more so than Coca-Cola.

Critics call it the “Coke-colonization” of the world, complaining initially about the erosion of local cultures but more recently about Coke’s contribution to significant increases in obesity rates in developing countries. The Economist’s December 2012 obesity report said that a combination of unreliable tap water and savvy marketing have helped make Mexico the world’s leading guzzler of Coca-Cola. For many campaigners, this is enough to explain Mexico’s rapid rise in obesity rates, which now match those north of the Rio Grande.

Lessons learned

As health campaigners and governments address the global obesity “pandemic,” food and drink companies can expect a storm of regulation in the coming years. An editorial in The Lancet, a leading medical journal, recently suggested that anti-alcohol and fast-food campaigners could draw valuable lessons from the fight against tobacco. The WHO’s commitment to combating NCDs and its new focus on obesity can lead in only one direction.

The story of tobacco regulation is familiar. Government campaigns discouraging consumption, starting famously with James I of England’s “Counterblast to Tobacco” of 1604, and taking firm root in the 1960s in the U.S. and the U.K., were followed by health warnings on packs and advertisements. Taxation, always attractive to governments, became a win-win tool as it was exploited to help smokers help themselves, while handsomely lining state coffers.

Governments then crafted regulations with the goal of modifying the product by reducing tar-per-cigarette levels, although they no longer appear to favor this approach and are now turning to banning ingredients, such as menthol. Further encouragement to quit was given to the smoker when the nonsmoker was identified as a victim in need of protection, and public smoking bans became widespread. The consumer’s freedom to learn about new products became increasingly curtailed by advertising bans. Finally, when only packaging remained as a means for cigarette manufacturers to communicate with consumers, some countries, such as Australia, decided that this too must stop.

Different target, same methods

The lessons learned from tobacco are already starting to be applied to sugar, as demonstrated by Michael Bloomberg’s (unsuccessful) attempt to limit the size of sugary drinks when he was mayor of New York City. Many call for more information about sugar to be printed on packs and cans. Thirty-three U.S. states have already introduced soda taxes.

But a “fat tax,” like that introduced—and then abolished—by Denmark, can be difficult to get right. Might regulators see packaging and promotion as an easier target? How long before the iconic Coke bottle—a trademark in its own right—is threatened with standardization? No doubt survey evidence from young consumers (unable to make informed choices) will be produced to show that they find the bottle shape and the red curlicue script attractive. If such “evidence” was enough for Australia—and now, apparently, the U.K.—to justify standardized cigarette packs, might  it  be used one day to introduce similar measures to crack down on the consumption of sugar?

Just as health campaigners adopt the lessons of tobacco control in determining the means of reducing consumption, so they are likely to adopt the same methods. For example, cooperate with industry at the outset, but marginalize and demonize it down the line. In the sugar-control arena, this is already contentious. Some talk of the bad behavior of industry, arguing that business is so conflicted it cannot be trusted. Litigation, which proved so popular in the U.S. as a way of driving tobacco regulation, is also advocated against fast food and soda drink producers.

However, others argue that self-regulation should be given a chance. For the time being, the WHO appears to favor cooperation, in contrast to its approach toward tobacco, where engagement and dialogue are proscribed. How long this willingness to treat the food and drink industries differently will last must strike those who follow the WHO’s Chan. In a recent speech at the Global Conference on Health Promotion, she said, “It is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda and Big Alcohol. All of these industries fear regulation, and protect themselves by the same tactics.” But while Chan brackets these industries together, they appear to defend their interests largely on their own.

Meanwhile, the tobacco industry bears a great responsibility, on behalf of all lifestyle product manufacturers, to defend against unreasonable regulation. Should it fail, its defeats will surely be visited upon the other industries, like sugar, that are seen as the next targets.

For example, if the World Trade Organization’s Dispute Panel upholds Australia’s plain packaging legislation, it will make it difficult for other industries to employ international trade laws to protect their own intellectual property—the brands and trademarks grown and matured over many years and at great expense. Perhaps it is encouraging to note that a number of the countries contesting the Australian law, including Cuba, the Dominican Republic and Honduras, produce not just tobacco but also sugar. Is it possible that without a successful outcome in Geneva, the Coke bottle may indeed one day become a collector’s item?

Simon Roper is an experienced lawyer who joined the industry in the mid-1990s when tobacco litigation flared around the world. Recently, he has worked on defending the sector’s interests against unreasonable regulation, such as plain packaging. He is now consulting and lives in Geneva, Switzerland. 

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