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Comments and proposals on tobacco control measures for the next campaign
plan for promoting national health (Health Japan 21 (third) program)
26th February, 2023
Manabu Sakuta, Chairperson, Japan Society for Tobacco Control, Generalincorporated
Thank you for your ongoing efforts to promote citizens’ health, especially thetobacco control measures related to the mission of this society. I would like tostate the following comments and suggestions, so I kindly ask for your attention.

【Summary】
I believe that tobacco control measures for the next campaign plan for promoting
national health (Health Japan 21 (third) program) should emphasize the following
three points.
(1) In accordance with the FCTC (Framework Convention on Tobacco Control), theJapanese government oversees ministries and agencies to coordinate and to advancetobacco control measures as a priority ( sections 1-4, 9)(2) Targeting a zero smoking rate and aiming for a nation without harms fromtobacco (sections 5-8)
(3) Targeting zero passive smoking and aiming for a society without passi ve smoking(section 9)
1. Steady implementation of the FCTC (Framework Convention on Tobacco Control)
is essential.
For promoting citizens’ health through tobacco control measures, as mentioned
in document 2 of this program, "steady implementation of toba cco control measures
is necessary in order to avoid immediate and future health effects and economic
losses and to fulfill our international obligation as a signatory to the FCTC
(Framework Convention on Tobacco Control)."
From page 37 of https://www.mhlw.go.jp/content/10904750/001049796.pdf
2. In accordance with the FCTC, tobacco control measures ought to be coordinatedand supervised across ministries and agencies .
In the final evaluation report of the second program of Health Japan 21,
chapter 3, section 2, page 348, as well as in other references, there is thefollowing statement. Based on this, as the Ministry of Health, Labor and Welfare
coordinate the polices across government ministries and agencies, I would like forthe government to advance these important policies:• From the view of protecting the health of citizens and based on the intentof the Framework Convention on Tobacco Control; it is urgent to combine
revisions to existing regulations and to strongly promote a re -considerationof the optimal tobacco tax rate, a society free from u ndesirable passive
smoking, regulations for warning images on tobacco products, implementing
anti-tobacco media campaigns, support and treatments for smoking cessation,and necessary and consistent compliance with regulations on tobacco
advertising, sales promotions and sponsorship activities.”
From page 348 of https://www.mhlw.go.jp/content/10904750/001000514.pdf
Many other countries have already developed policies in this regard. To apromulgate a national policy, in accordance with the FCTC, it is essential tocoordinate policies across ministries and agencies, to promote smoking cessation(zero smoking), and to protect non-smokers--who account for 85% of citizens-from the harms of passive smoking (zero passive smoking). Without these policies,
the health of citizens can not be protected from the harms of tobacco.
3. Without FCTC compliance throughout the natio n, there are limits on the efforts
of local governments and private organizations.
Besides the ordinances to prevent passive smoking that each local
government can enact under the Health Promotion Law, there are very few tobacco
control measures that can be decided by regional and municipal official s. It isalso difficult to improve the effectiveness of local plans even if they submitted
to prefectural policy makers.
Unless the national government fully promotes the measures described in
sections 1 and 2 in accordance with the FCTC, it will be difficult to achieve
results through the efforts of local governments and private organizations alone.
4. It is essential to design a system that complies with the guidelines for
implementing Article 5.3 of the FCTC.
Similar to tobacco control measures at the national level, it is also truethat measures by local governments are being hindered by the tobacco industry.
For example, many difficulties have arisen when trying to enact ordinances toprevent passive smoking.
This is because the guidelines for enforcing Article 5(3) of the FCTC, "toprotect public health policy related to tobacco regulations from commercial andother existing interests of the tobacc o industry", have not been implemented inJapan. It is indispensable that the Japanese government complies withlegislation and institutional designs (including prohibitions and otherregulations for political contributions).
https://www.mhlw.go.jp/topics/tobacco/dl/fctc_5 -3_guideline_120506.pdf
5. A goal of a zero smoking rate is needed so that all smokers qu it smoking.

As written in the fundamental policy document (see the link below), tobacco
causes disease and early death, and impairs a healthy life span.
It is explicitly written below that decreasing tobacco consumption can reliably
reduce excess deaths, excess medical expenses and other economic losses fromsmoking-related diseases such as cancer in the future.
https://www.mhlw.go.jp/content/10904750/001049796.pdf From page 37"background"
Smoking rates have been steadily declining for several decades. This trend
shows that the harms from tobacco are well known, that people are becoming more
health conscious, and that we understand that tobacco is unnecessary in ourlives.
Besides setting numerical targets based on the idea that "those who wantto quit will quit", it is possible to augment the number of smokers who want toquit by expanding the health awareness of citizens and making us fully aware of
the harms from tobacco, as described above. Combining both possibilities, I thinkthat we ought to aim for a Japan without harms from tobacco with a target of "azero smoking rate for all smokers who quit".
6. Policies for all smokers to quit tobacco
As for the above policies cited in section 2, it is indispensable for the Japanese
government to implement coordinated policies across various ministries and agencies
in accordance with the FCTC.
But for measures under the jurisdiction of theMinistry of Health, Labor and Welfare, I think that the following might be useful.
(1) Regarding smoking cessation treatment
・Relaxation of insurance requirements for smoking cessation treatment (possible
during hospitalization, extension of treatment periods, possible retreatment
within one year, elimination of compulsory requirements for CO measurement,et cetera.)・Expand insurance coverage of smoking cessation treatment to dental diseases
such as periodontal disease
・Encouragement and promotion of smoking cessation treatment in workplaces andinsurance associations (through health insurance,
health insurance plans, and other methods.)

cooperatives, national

・Implement training such as cognitive behavioral therapy for smoking cessation
treatment in prefectures.
(2) Set numerical targets for smoking cessation treatment s and examinations inprefectures.
(3) Increase availability of smoking cessation medicines (shipment of varenicline
is currently suspended, and outpatient facilities for smoking cessation areoften closed: discussion by Chinese medical association needed).

(4) Specific health diagnostic examinations; specific instructions for healthpromotion; asking "smoking"-related questions in health diagnoses at workplaces,universities and other institutions together with advice and incentives to quit
smoking; referrals to smoking cessation treatment facilities.
(5) Anesthesia guidelines are known to state that smoking cessation is now
required before surgery.
(6) Expansion and thorough enforcement of non-smoking areas (enhancing measures
to eliminate passive smoking). Details are in section 9.
(7) Including the aforementioned points, I think that we can expand collaborationand cooperation in the various fields related to health promotion, including by
medical organizations, practitioners and administrators, and that we can develop
assistance plans from national and regional governments toward a target of azero smoking rate.
7. Regarding the elimination of smoking for those younger than 20
Denmark, Malaysia and other countries have moved forward with legislation
regulating tobacco vending machines, allowing smoking cessation treatment andexamination at outpatient clinics and ‘prohibiting smoking for people born after
2010', which was also passed in New Zealand. These types of legislation can also
spread to other countries in the future. I think enacting such legislation would
be effective in Japan too, so please consider these as potential measures.
8. Regarding the elimination of smoking during pregnancy
There seem to be many reports that smoking by pregnant women has not decreased,
and there also seems to be reports that this behavior is related to healthdifferences. As mentioned in section 9 (9), a national survey found that about
2% of pregnant women smoke. I would like to ask you to consider legislation at
the national level, including smoking restrictions and regulations fully dealing
with the person herself, her cohabiting husband (spouse) and family members.
9. We should set a target of zero passive smoking and aim for a society without
passive smoking.
The guidelines for implementing Article 8 of the FCTC “Protection fromexposure to tobacco smoke”
https://www.mhlw.go.jp/topics/tobacco/dl/fctc8_guideline.pdf clearly states
the following, so it is essential to implement effective policies for zeropassive smoking in accordance with these guidelines.
“Everyone should be protected from exposure totobaccosmoke.

Indoorworkplaces and indoor public places should be completely smoke-free.”“Protective measures must be taken in outdoor or semi-outdoor public areas.”

“Effective measures

to protect against exposure to tobacco smoke

musteliminate smoking and tobacco smoke from designated spaces in order to create a
100% smoke-free environment.
There is no safe level of exposure to tobaccosmoke,… and it has been repeatedly shown that approaches other than 100% smokefree environments are ineffective in eliminating exposure to tobacco smoke .
Engineered barriers or methods can not protect against exposure to tobacco smoke.”・In this third plan, the target of “reducing the number of persons who havepossible exposure to passive smoking” is in chapter 4 Target setting 2. Specifictargets 2-1. Improving lifestyle habits <5> Separating smoking from numericaltargets for smoking (page 37 from the link below),(3) Improving the quality of the social environment 3-2. It has been changed
to create an environment that becomes healthy and natural, and the target value
is stated as "realization of a society without u ndesirable passive smoking (by2032)". (But I do not understand why they were separated.)③ Reducing the number of persons who have the possibility of undesirable
passive smoking
59-61

https://www.mhlw.go.jp/content/10904750/001049796.pdf

pages・However, the expression "undesirable" is fundamentally incorrect and improper.
The harm of passive smoking affects everyone who is exposed. No one "desires"it, and everyone is harmed, even if a person does not mind or is not aware ofit, including those who are unwilling or unable to express their desires likechildren, infants and fetuses.
Eliminate smoking for those younger than 20, eliminate smoking during pregnancy,
as well as setting a target of "0% passive smoking" and (3) eliminate thepossibility being exposed to passive smoke. Objective: realization of a society
without passive smoking. I concur that exposure to passive smoking should be 0%.
・Moreover, I think that it would be better to not separate this target for passive
smoking from the numerical targets of <5> smoking (pages 37-39 of the above link)
and to state the same set of four targets (zero targets) as in the second planfor Health Japan 21.
・It is important to assemble a specific plan to achieve zero passive smoking,just as it is to eliminate smoking by those younger than 20 and to eliminatesmoking during pregnancy. No one desires to be harmed by passive smoking, so I
think that it would be better to set separate zero passive smoking targets by area.
(1) Because educational and child welfare facilities, administrative agencies andmedical institutions are stipulated as Type 1 facilities under the Health Promotion
Act, it is given that these places should have zero passive smoking. Regarding
designated outdoor smoking areas, there are many cases where re gulations are notstipulated by ordinance. And when regulations are not stipulated , there are manycases where harms from passive smoking have been reported, including in cases ofregulatory exemptions, although public attitudes might imply that passive smoking
does not cause harm. We should therefore set a target of zero passive smoking.
(2) Workplaces in type 2 facilities are expected to be stipulated as non-smoking
indoors, but even so realization of zero passive smoking can not be maintained.
The exclusive rooms for smoking can be defective, and it is necessary to thoroughly
implement zero harm from passive smoking by revising and reviewing ministerialordinances. (Smoking is prohibited on the premises of the judicial bodies of Type
2 facilities, and similarly 3.3% of legislative bodies (the Diet or Parliament) of
Type 2 facilities have designated smoking rooms and should be classified as Type1.)(3) According to the Occupational Safety and Health Survey, the “percentage ofworkers having passive smoking in the workplace” was 20.7% in 2021, 20.1% in2020 and 28.9% in 2019. Although this might appear to be progress, i t is necessary
to clearly specify and to thoroughly implement zero passive smoking.
https://www.mhlw.go.jp/toukei/list/dl/r03 -46-50_gaikyo.pdf(4) Regarding restaurants, in the 2021 survey linked below, 83.2% of cafeterias
and restaurants are completely non-smoking indoors, while 3.7% have designatedsmoking rooms and 13.1% have another or unknown status. Because the percentage ofindoor smoking bans is declining at (new and established) cafes, pubs, bars andother shops; it is necessary to thoroughly implement zero passive smoking. (Inparticular, transitional steps to allow smoking in shops with a guest area of 100m 2
or less ought to be abolished.)
Ministry of Health, Labor and Welfare: Survey results from the 2021 “ Factual
survey on smoking environments” (Summary)https://www.mhlw.go.jp/content/10900000/001043203.pdf(5) In Type 2 facilities like social welfare facilities, conference halls and otherpublic facilities; permission for indoor smoking is about 80%-90%. The resultsfrom 2021 do not show progress compared to 2020 data, and it is necessary tothoroughly implement zero passive smoking.
(6) Smoking bans are moving forward somewhat in parks, theme parks, amusement
parks, outdoor sports facilities, game arcades and entertainment facilities; but
it is still necessary to thoroughly implement zero passive smoking.
(In the public opinion survey from the Cabinet Office on tobacco control measuresin (8) below, 35.9% of respondents replied that "parks and playgrounds wherechildren play outdoors" were unpleasant, so it is necessary to thoroughly implement
zero passive smoking.)(7) Private rooms in admission facilities (like facilities for supporting motherswith children, intensive-care elderly homes, fee-based elderly homes, group homes,
housing with home care services, facilities for persons with disabilities, small
multi-purpose residence nursing facilities, first aid facilities, social welfarefacilities) (places that provide human residence or extended stays) are exemptedfrom applying smoking bans (Article 40 in the law). Although it is stipulated
that smoking is generally prohibited in common areas (a designated smoking room
can be installed), there are many reports that passive smoke leaks and emanates
inside the facility, causing harm. According to this revision and review, it isnecessary to thoroughly implement zero passive smoking.
(8) In the "Public opinion survey concerning tobacco control measures" conductedby the Cabinet Office in 2022, smokers were asked where they were uncomfortablewith tobacco smoke. I was reported that 70.2% answered "on the street" (in theprevious survey, 53.3%), followed by 50.9% who answered at restaurants and shopsthat mainly serve meals (in the previous survey, 62.4%).
https://survey.gov-online.go.jp/hutai/r04/r04-tabako/gairyaku.pdf
・ Streets should be included in the targets for eliminating passive smoking
according to the Health Promotion Law. Given that open designated smoking areas
are often established on the city streets, a significant fraction in the Cabinet
Office survey, 39.4%, replied that they were uncomfortable “near an outdoor
smoking area”. It is necessary to thoroughly implement zero passive smoking on
the street and outdoors.
・In addition, it has been pointed out that the notice from the Director of theHealth Bureau of the Ministry of Health, Labor and Welfare that is titled "Regarding
technical matters for outdoor segregated smoking facilities" does not prevent
passive smoking outdoors or on the street. Because these facilities are instead
identified as a source of passive smoking, it is necessary to abolish them.
https://notobacco.jp/pslaw/okugaibunnenns hisetsunogijyutsutekiryuuijikounitsuite.pdf(9) Prevention of passive smoking in homes and private cars might be aspects
outside the scope of the law because these are completely private spaces, but thebaseline exposure rate in 2019 was 7%. According to "Status of implementing
maternal and child health services" from the Ministry of Health, Labor and Welfare
in 2021, 1.9% of pregnant women smoke, 5.3% of mothers smoke while raising children,and 31.4% of fathers smoke. So passive smoking by children and cohabiting family
members is probably not zero.
2021 Status of implementing maternal and child health services
https://www.mhlw.go.jp/stf/newpage_30143.html
・Regarding smoking in homes and private cars, broadcast the fact that exposure topassive smoking for infants, children and minors constitutes child abuse. Because
evidence of risks like cancer also exists for cohabitating members besides children,
zero passive smoking in homes and private cars is essential.

・In addition, places like Hyogo Prefecture and Bibai, Hokkaido have establishedregulations that prevent passive smoking and prohibit smoking in the same room or
the same car as pregnant women. I think that this country needs to step up its
efforts in restrictions and regulations.
are prohibited from smoking.

For example, pregnant women in Taiwan

This is also necessary as a stategy against adeclining birthrate, which is now an urgent issue for the country.
(10) As mentioned above, it is desirable to have policies and targets that highlight"zero passive smoking". In anticipation of the revision of the Health Promotion
Act in 2025, it is desirable to strengthen and to revise regulations and laws.
10. Related to the prevention of harms from passive smoking and tobacco control
measures more generally, I have enumerated the following subjects that were notlisted above. Please heed these too.
(1) The government will provide subsidies (including organization of subsidies forprefectures and municipalities) for the renovation of shops where smoking is currently
allowed into non-smoking shops.
(2) In condominiums and detached houses, there is an increase in damage and troubles frompassive smoking from neighbors and the community. (According to the Cabinet Officepublic survey described in 10.(8), 20.8% of respondents replied that passive smoking
was unpleasant.) I would like the government to consider such policies and to realize
zero passive smoking.
(3) The tobacco industry declares that tobacco is a "luxury product", but Kojien (Japanesedictionary), Digital Daijisen (electronic dictionary) and Wikipedia do not mention
tobacco as a "luxury product", and tobacco is no longer included as a "luxury product".
Tobacco should be called an "addictive product".
I would like the Ministry of Health, Labor and Welfare to use the expression "addiction"
so that tobacco is not described as a "luxury product".
(4) In the future, due to the increase in the number of foreigners working, studying,living and visiting; the need for tobacco control measures, education, and publicawareness will rise to prevent troubles related to the prevention of passive smoking.
Please consider how to deal with this.
(5) Exaggerated advertising and publicity for heated tobacco is becoming a concern. Someare pushing to strengthen the dependence of tobacco among young people by using
additives like menthol and other flavors. Like in other countries, it is becoming
necessary to ban and to regulate additives and to limit advertising and sales promotion.

Conclusion