The last decade has seen unprecedented achievements in global tobacco control. These include the entry into force of the WHO Framework Convention on Tobacco Control (WHO FCTC) and 179 states, as well as the European Union, becoming Parties to the Treaty, leading to an increased global cognizance of the negative health and economic impact of tobacco use. Governments around the world continue to adopt and implement effective tobacco control strategies and financial contributions from major philanthropies have increased the levels of financial support for tobacco control efforts in low- and middle-income countries. The UN high-level summit on Noncommunicable Diseases (NCDs) in 2011 and the 2015 adoption of the Sustainable Development Goals (SDGs), in which NCDs and acceleration of implementation of WHO FCTC are included as specific targets, represent an increased global recognition of the need to address tobacco use prevalence as a key element of NCD interventions.
That said, the past 10 years have also obstacles substantive challenges. There were, and still are, shown and setbacks, as well as political challenges and an increasing resistance to tobacco control measures by the tobacco industry. These challenges require a coordinated response in order to effectively combat the global tobacco epidemic.
Globally, only around 1 in 3 countries run strong surveillance systems that monitor tobacco use effectively. Even fewer are monitoring the impact of tobacco control policies. Almost all countries are running regular household surveys covering health topics or drug use, which presents an opportunity to incorporate Tobacco Questions for Surveys (TQS) at minimal additional cost. TQS is a minimum set of questions that covers the basic information needed to monitor the tobacco epidemic.
Since 2005, tobacco smoking has globally been trending slowly downwards. WHO estimates that the proportion of people aged 15+ who smoke has decreased slightly from 24% in 2005 to 21% in 2015 (prevalence remains high among men (over 35%) and lower among women (under 9%) globally).
As the number of countries with complete smoke-free environments continues to rise (49 countries globally), it has become evident that effective laws are comparatively easy to pass. However, achieving high levels of compliance with smoke-free legislation continues to be a major challenge in many countries. Efficient smoke-free legislation comprises a duty of compliance by businesses owners, managers and smokers, with businesses required to take necessary steps such as posting “no smoking” signs, removing all ashtrays, supervising adherence to the rules and taking measures against persons who break the rules. Penalties for incompliance with this legislation should be targeted at businesses rather than individual smokers and should be considerable and/or serious enough to prevent violations. Additionally, the authority in change of enforcement should be identified within the respective law, as should a system for monitoring compliance and prosecuting violators.
Many countries globally ban at least some forms of tobacco advertising, promotion and sponsorship (TAPS). However, only comprehensive bans, covering all advertising channels including point-of sale bans and banning of Corporate Social Responsibility activities, are effective in counteracting the tobacco industry, and only 29 countries globally have put in place such comprehensive bans. Political determination at the highest levels of government is required to enact and enforce effective TAPS bans, as well as to counter the predictable resistance from the tobacco industry and the interrelated groups and industries that benefit from TAPS expenditures.
Large pictorial health warnings labels on tobacco packaging inform about the risks of tobacco use, can reduce tobacco use and can be implemented at practically no cost to governments. Globally, 42 countries have large, graphic warnings in place, covering at least 50% of the package. The tobacco industry uses many tactics to prevent or delay implementation of health warnings. Spurious industry arguments can be countered with facts about the effectiveness and legality of large, graphic warning labels.
Plain (standardized) packaging of tobacco products reduces the attractiveness of tobacco products, limits advertising and promotion on product packaging, minimizes misleading packaging and boosts the effectiveness of health warnings. In December 2012, Australia became the first country to implement plain packaging on all tobacco products, and more recently UK and France have adopted plain packaging legislation. Despite the tobacco industry’s rigorous efforts to block plain packaging, a growing number of countries are taking this step.
Tobacco taxation is one of the most effective and cost-effective tobacco control policy interventions. Increase in excise taxes, which results in increases in prices reduce tobacco consumption through increased cessation, reduced smoking intensity and reduced smoking initiation. Tobacco taxes represent a “win-win” for public health and public finances, yet tobacco taxes remain the least implemented tobacco control policy measure globally.
A number of challenges drive the poor implementation of tobacco taxes. Firstly, in many countries a lack of collaboration between the health and finance sectors means a poor understanding of the health implications of tobacco use by the finance sector, and a poor understanding of the health benefits of reduced tobacco use as a result of tax increases. In many cases the finance sector is under the false impression that increases in tobacco taxes will reduce revenues and present threats to the broader economy. Secondly, while increasing tobacco taxes are effective, complex and weak tax structures result in the benefits of reduced consumption and increased revenues being undermined. There is a consensus that countries should implement excise tax systems that are simple and emphasise specific taxes. However, many countries still rely on tiered and ad valorem systems with poorly defined tax bases. Thirdly, poor tax administration systems means that taxes can be under collected and undermined by the illicit trade in tobacco products.
Countries should ensure that tax and prices increases are large enough and regular to ensure that tobacco products become less affordable over time.
Illicit trade in tobacco products can undermine tobacco tax systems as well as tobacco control policies, thereby increasing tobacco use. Hoping to deter governments from increasing tobacco taxes, the tobacco industry argues that tax increases lead to illicit trade. However, evidence from around the world shows that even in the presence of illicit trade, tax increases still lead to higher tax revenues and real reductions in tobacco use. The WHO FCTC Conference of the Parties (COP) adopted at its 5th session the Protocol to Eliminate Illicit Trade in Tobacco Products. The protocol highlights the need for strong control of the tobacco product supply chain as part of an effective approach to stemming illicit trade.
Tobacco Industry Interference
The tobacco industry mobilizes substantial resources for a wide range of tactics to weaken, undermine, and obstruct effective implementation of the tobacco control measures of the WHO FCTC. Some activities are conducted candidly, while others are more concealed. Tobacco Industry interference tactics include:
Hijack the political and legislative process;
inflating the economic importance of the industry;
manipulating public opinion to gain the facade of respectability;
constructing support through front groups;
discrediting proven science; and
threatening governments with litigation or the threat of litigation.
All industry attempts at interference -if recognised and regularly monitored- can be successfully thwarted - identifying and understanding the several tactics is crucial.
Implementing effective tobacco control measures in every country is neither quickly achievable nor easy. It can be difficult to generate enough political will to adopt and implement strong tobacco control laws and to be able to overcome the strong opposition from the tobacco industry.
But evidence from around the world shows that it is possible for all countries, independent of the income level, to protect the health of their people. Numerous governments around the world have identified and put in place the most cost-effective measures for reducing tobacco use in line with the WHO FCTC, such as:
reducing the affordability of tobacco products by increasing tobacco excise taxes;
creating completely smoke-free environments in all indoor workplaces, indoor public places and public transport;
warning people about the dangers of tobacco through effective health warnings and mass media campaigns; and
banning all forms of tobacco advertising, promotion and sponsorship.
Because tobacco control is a multisectoral issue, a “whole of government” approach - as suggested in the WHO FCTC - is required to successfully strengthen efforts so that more people are fully protected from the tobacco epidemic and its harms.
The authors are staff members of the World Health Organization. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the World Health Organization.
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