Judith MacKay learned early on in her career to wear insults as a badge of pride. “A gibbering satan”, prone to the use of “diatribes full of putrid corruption, lies, conspiracy, and total censorship” is just a taste of the many slurs that came MacKay’s way in the early 1990s. What MacKay had done to merit such attacks from US smokers’ rights groups was what she has been doing since the early 1980s: tirelessly and effectively advocating for better control of tobacco products around the world, but in Asia in particular.

As MacKay and her colleagues explain in their paper on Tobacco Control in The Lancet, as well as being one of the biggest markets for tobacco, Asia has also been at the forefront of efforts to control its use. MacKay has been a central figure in that cause. Born in Saltburn by the Sea on the UK’s northeast coast, MacKay moved to Hong Kong with her husband in 1967 after graduating in medicine from the University of Edinburgh at the age of just 22 years. And after a brief hiatus to do what she calls “a few traditional things like having babies”, and brushing up on her Cantonese, her increasing involvement with the feminist movement led MacKay to think more seriously about a long-term career.

She went back to medicine, and as a specialist in internal medicine at Hong Kong University’s hospital MacKay started to see more and more patients with tobacco-related diseases. It dawned on her that there was a pressing need “to go further up the river in public health terms”, and at the same time, she says, she was “very interested in health education, and was writing 1000 words a week for the South China Morning Post for a column on women’s health”. It was the “ballistic”, vitriolic response of the tobacco industry to a series of MacKay’s articles on women and tobacco that finally affirmed tobacco control in her mind as the cause to which she should devote her life’s work. “I left clinical medicine in 1984”, she says, “and I never looked back really”.

So how do you go about setting yourself up to influence government tobacco policy? It’s not something, as a rule, that tends to come up in medical curricula. “I was never trained on how to lobby a finance minister for a tax increase, or put out a press release, or front up to a very powerful industry”, says MacKay. But she was steadfast in the face of industry intimidation and, importantly, “she had the ear of governments because she has a persuasive style rather than confrontational approach—a skill much appreciated when dealing with conservative style Asian governments”, says Mary Assunta, Director of the International Tobacco Control Project run by Cancer Council Australia.

Working alone and often unpaid for 25 years, MacKay’s appointment in 2006 as Senior Advisor to both the World Lung Foundation component of the Bloomberg Initiative to Reduce Tobacco Use in low-income and middle-income countries and the Bill and Melinda Gates Foundation reflects the huge change in attitudes towards tobacco over the intervening years. “It’s institutionalised now”, she says: “it’s become mainstream public health in a way, whereas back in the 70s and 80s it was seen as very quirky. There was a caution and a real feeling that somehow I’d gone off the main tracks of medicine, but nowadays the understanding is much wider than it was before.” Through the WHO Framework Convention on Tobacco Control to new funding from Bloomberg and the Bill and Melinda Gates Foundation, there is a real momentum now behind tobacco control. “Almost every day I get something in the inbox about a new law that’s been created or expanded or implemented”, MacKay says. But there is also a real need to ensure that progress does not breed complacency.

The tobacco industry is no different than it has ever been, MacKay warns, although their tactics have evolved. “They’ve tried to attack the science, then moved on to attacking individuals like myself, and now they’ve moved to attacking governments”, she says. The Australian Government’s recent decision to introduce plain packaging for cigarettes attracted a lengthy challenge in the Australian High Court, along with an ongoing dispute in the World Trade Organisation. It’s a familiar story according to MacKay. “In the same week, the Minister of Health from Scotland and the Minister of Health from Iran said the same thing to me: ‘we’re bogged down with legal challenges’. It’s a delaying tactic, and they’ve delayed some legislation in India for example for almost a decade”, she notes. But apart from delaying the adoption of graphic warning labels on cigarette packaging in the USA, these challenges have been unsuccessful. “It’s a paper tiger”, she says.

The same can’t be said of MacKay herself, and she is in no doubt that over the next few years she can help persuade more governments to start setting targets and consider endgames, such as New Zealand’s recent announcement of a goal to reduce smoking prevalence to 5% by 2025. An endgame for MacKay, though, is something she’ll not be considering any time soon. “That’s the wonderful thing about public health, you can go on forever”, she says. “I really quite seriously think I’ll be campaigning on my 100th birthday.” And for the tobacco industry representatives who she assures me will be poring over this article, there can’t be much worse news than that.

Source: Lancet