Chapter 6: Neglected Global Epidemics: three growing threats
Tobacco control: strengthening national efforts
The consumption of cigarettes and other tobacco products and exposure to tobacco smoke are the world's leading preventable cause of death, responsible for about 5 million deaths a year, mostly in poor countries and poor populations. Latest estimates reveal that, of the nearly 4 million men and 1 million women who died, over 2 million men and 380 000 women were in developing countries (12). The toll will double in 20 years unless available and effective interventions are urgently and widely adopted.
Globalization of the tobacco epidemic can undermine even the best national control programme. The epidemic is being spread and reinforced worldwide by a complex mix of factors with cross-border effects, including trade liberalization, foreign direct investment, and other factors such as global marketing, transnational tobacco advertising, promotion and sponsorship, and the international movement of contraband and counterfeit cigarettes. Recognition of this situation led to the adoption by 192 Member States at the World Health Assembly in May 2003 of the WHO Framework Convention on Tobacco Control (WHO FCTC). This, the first treaty negotiated under the auspices of WHO, constitutes a major turning point in tackling a major global killer: it signals a new era in global and national tobacco control activities. The FCTC is an evidence-based treaty that reaffirms the right of all people to the highest standard of health. It represents a paradigm shift in developing a regulatory strategy for addictive substances: in contrast to previous drug control treaties, the FCTC asserts the importance of demand reduction strategies as well as supply issues.
Major challenges lie ahead as WHO works with Member States to implement the agreement in countries. The process of the FCTC's creation also reveals the price paid for delay between vision and action. It has taken almost 10 years to bring the idea of such an instrument to fruition. During that time, more than 30 million people have died of tobacco-related illnesses, 70% of them in low-income and middle-income countries and half before the age of 70. Those who died before 70 years of age lost, on average, 28 years of life (13). As entry into force of the Convention draws nearer, strengthening national capacity in tobacco control becomes an important public health priority in all countries.
This section looks forward to the timely ratification, entry into force, and implementation of the FCTC and the opportunities thus presented for further progress in national tobacco control. It also examines the challenges of building and strengthening national political, managerial and technical tobacco control capacity.
Guiding tobacco control
Total tobacco consumption is on the rise. The number of smokers in the world, estimated at 1.3 billion today, is expected to rise to 1.7 billion by 2025 if the global prevalence of tobacco use remains unchanged (14). Every second smoker will die of a tobacco-caused disease. Until recently, the global response to this major public health challenge had been inadequate.
In May 2003 the World Health Assembly adopted by consensus the WHO Framework Convention on Tobacco Control (FCTC). Negotiated among WHO Member States over four years, this international legal instrument is designed to limit the harm to health caused by tobacco products. It comprises many diverse aspects of tobacco control, including: advertising, promotion and sponsorship; packaging and labelling; price and tax measures; sales to and by young persons; passive smoking and smoke-free environments; and treatment of tobacco dependence. The Convention represents a global minimum standard, and the future Parties to the Convention are encouraged by provisions in the treaty to go further and implement stricter measures. Furthermore, the negotiation of future protocols to the Convention by the Conference of the Parties will result in a treaty regime that will continue to evolve and to provide for more specific obligations on certain topics. The FCTC is a delicately balanced instrument adopted after vigorous negotiations, which took into account relevant scientific, economic, social and political considerations.
The FCTC's adoption by the World Health Assembly opens the treaty for signature and ratification by individual Member States. The Convention is available for signature from 16 June 2003 until 29 June 2004, and from 30 June 2004 for ratification.
The signing of the Convention indicates a Member State's intention to ratify the treaty but does not carry substantial obligations other than agreeing not to undermine the objective of the Convention; it provides, however, an important political commitment by a country to move towards ratification. Ratification provides the consent of a country to become legally bound by the treaty and commits it to implement the provisions of the treaty in good faith once the treaty enters into force. The Convention will come into force of law 90 days after the treaty has been ratified by 40 Member States. At that time, countries that have ratified it will be legally bound by its provisions. Countries that do not ratify the treaty are not obliged to implement its provisions.
Not all treaties provide for funding and technical assistance for the implementation of the instrument. The FCTC, however, belongs to the unique family of international agreements that undertakes to provide for such resources. The Convention commits Parties to provide funding for their national tobacco control measures, encourages the use of innovative national, regional and international funding mechanisms to provide additional resources for tobacco control, and leaves the question of the possible establishment of a voluntary global fund or other appropriate financial mechanisms to be determined in the future by the Conference of the Parties. As evidence of the power of the FCTC process, the issue of tobacco control has been placed firmly on the agenda of development funding as a priority.
As in the negotiation of the FCTC, tobacco control activists in health professions, concerned nongovernmental organizations and grass-roots groups have an important role on the international stage during the ratification process. They can continue to promote the ratification and implementation of the FCTC and the introduction of effective national legislation in support of the Convention.
National policies and programmes
A comprehensive public health approach to tobacco control effectively prevents the beginning of tobacco use and promotes its cessation, through a range of measures including tax and price policy, restrictions on tobacco advertising, promotion and sponsorship, packaging and labelling requirements, educational campaigns, restrictions on smoking in public places and cessation support services. A comprehensive approach must include young people and women and reach the entire population.
National policies must also confront fresh challenges such as regulatory frameworks for new tobacco products that are just beginning to appear on the market. Moreover, with the adoption of the FCTC, the definition of a comprehensive tobacco control strategy has now been redefined to include the transnational components of tobacco control, as a complement to national and local measures.
Few countries have implemented the comprehensive measures needed to create a significant decline in tobacco use. The policy measures known to have the biggest impact on individual levels of consumption, cessation rates and initiation rates require sustained political will and engagement, and above all effective and well-enforced legislation.
The capacity for effective tobacco control is lacking in most countries. Most do not have the necessary infrastructure or human resources to sustain a basic tobacco control programme. As an example, few national governments have people working full-time on tobacco control. In many countries, civil society has not yet been mobilized around the issue, so even when governments have adequate political will to propose tobacco control measures, tobacco companies can easily oppose and weaken policies. Even where the ministry of health is supportive of action it may be unable to make its case successfully above the voices of other more influential ministries.
Building national capacity
The success of the Convention largely depends on countries ratifying the treaty and implementing effective tobacco control measures. Building and strengthening national capacity in political, managerial and technical aspects of tobacco control is the key to a systematic multisectoral approach. Only this approach will ensure sustainable community and governmental action for comprehensive tobacco control efforts at the local, national and global levels.
Many countries have not yet developed national plans of action for tobacco control, largely because of lack of consensus and political commitment. Where such plans exist, policy instruments may remain ineffective because of weak enforcement. Governments and civil society need to be convinced that investing resources to prepare for tobacco control will reap benefits in the medium and longer term. Continuous monitoring of tobacco industry activities and strategies will be required to counteract the industry's manoeuvres to undermine tobacco control efforts. Strong political commitment and engagement are essential.
While the health sector is in large measure supportive of tobacco control, it cannot on its own bring the resources, expertise and political will needed to advance change. This requires support and commitment from all the relevant sectors in the national government. Tobacco control efforts are more likely to be sustained when incorporated into existing national, state and district-level health structures.
The expected outcome of building national capacity is a comprehensive, effective and sustainable strategy for multisectoral national tobacco control programmes and policies. Here, the role of WHO is to coordinate global expertise, enhance leadership, facilitate assistance to front-line efforts, and promote partnerships with governments and civil society to foster the implementation of more effective tobacco control strategies. Many success stories are available to guide countries; two are summarized in Box 6.2.
Box 6.2 Examples of successful tobacco control strategies
Tobacco excise taxation in South Africa
The past 10 years have witnessed a major shift in government policy on tobacco control in South Africa, which rests on two important pillars: legislation and excise tax increases. The government elected in 1994 announced an increase in tax on tobacco products to 50% of the retail price (at that point, excise taxes amounted to 21% of the retail price and the total tax burden was 32% of the retail price). In 1997, the Minister of Finance announced that the 50% target had been achieved. Subsequent tax increases were aimed at keeping the tax percentage at the same level. Over the past decade the real retail price has more than doubled: cigarettes, compared with a basket of other goods and services, have become very expensive. Along with other tobacco control interventions, tax increases have contributed to a 33% reduction in tobacco consumption. In addition, real government revenue from tobacco taxes has more than doubled (15).
Health warnings in Thailand
The first health warnings on cigarette packets in Thailand were introduced in 1974. Since 1989, many changes have been made to the messages, as an important component of a comprehensive control policy. The health warnings were improved in stages, with a greater variety of texts and stronger language. The number of rotating warnings has increased from one to twelve. The size of the warning area on cigarette packages and cartons has increased to one-third of the principal surfaces. A new set of pictorial health messages, occupying half of the front and back display areas, was prepared and submitted to the Ministry of Health in 2003 and is currently awaiting the approval of the Government of Thailand. Per capita cigarette consumption has been decreasing since the mid-1990s as a result of Thailand's comprehensive control policies (16).
Integrating tobacco control into health systems
Treatment of tobacco dependence is another possible policy measure in low-income and middle-income countries (17). As the projections in Figure 6.2 demonstrate, a mix of effective prevention and treatment measures will avert significantly more tobacco-caused deaths within the coming decades compared with prevention alone (18). Cessation programmes for adult smokers are essential for rapid population health improvements over the next 20--30 years, since the benefits of preventing young people from taking up smoking will become apparent only after several decades. The Global Youth Tobacco Survey showed that most young smokers in the Western Pacific Region wished to stop smoking (see Box 6.3).
Figure 6.2
Box 6.3 Tobacco and schoolchildren in the Western Pacific Region
Alarmingly high rates of tobacco use and exposure to second-hand smoke among schoolchildren aged 13--15 years in the Western Pacific Region are revealed by data from the first group of countries within the Region to complete the Global Youth Tobacco Survey. Many of these children started smoking before the age of 10, and an overwhelming majority want to quit but are unable to do so because of nicotine addiction.
The survey involved China, Fiji, the Northern Mariana Islands, Palau, the Philippines and Singapore. It found that in some parts of China, between 20% and 40% of children started smoking before they were 10 years old, compared with 14% in the Philippines, about 22% in Fiji and Singapore, and 31--32 % in Northern Mariana Islands and Palau. Overall, between 35% and 65% had been exposed to others' smoke at home.
The desire to stop smoking was expressed by up to 87% of child smokers in China and 85% in the Philippines, and not less than 62% of all the children in the survey. These figures indicate an urgent need for interventions that target children and adolescents, to empower them to reject tobacco. For those already addicted, cessation strategies appropriate to this age group are imperative. In addition, there is a clear and pressing need for effective measures to ensure that children and young people are protected from the effects of second-hand smoke exposure. To protect children properly, WHO urges governments to establish comprehensive tobacco control programmes that adhere to the principles outlined in the Framework Convention on Tobacco Control.
The delivery of cost-effective treatment of tobacco dependence in most countries is hampered by many factors, including: the lack of integration of tobacco dependence treatment into health care systems; lack of skills of health care providers; high price of nicotine replacement therapy products and cessation services; and the strict regulation of such products. Support and greater access to treatment provided through the health care systems will help the poor populations who are most likely to smoke (19). All health providers must be involved, including oral health professionals who, in many countries, reach a large proportion of the healthy population. A supportive environment is essential to support smoking cessation programmes and this requires strong government action, for example, in the promotion of smoke-free environments and communication and awareness measures to reduce the social acceptability of tobacco use (20).
One of the most advanced mixes of population-level smoking cessation initiatives is in New Zealand, where 50% of the indigenous population are smokers (21). Services include a national Quitline, subsidized nicotine replacement therapy, Maori-focused services including quitting support and therapy for Maori women and their families, and a hospital-based quitting service. Key factors in establishing programmes including cessation activities are media campaigns, an active tobacco control lobby, proactive policy analysts and a supportive government; tax increases also create incentives to help people to stop smoking.
The FCTC is a global response to the pandemic of tobacco-induced death and disease. The opening of the Convention for signature and ratification provides an unprecedented opportunity for countries to strengthen national tobacco control capacity. Success in controlling the tobacco epidemic requires continuing political engagement and additional resources at both global and national levels. The resulting improvement in health, especially of poor populations, will be a major public health achievement.