2 September 2019
Ryan Forrest, Sara Rose Taylor and Mafoya Dossoumon
study published in the British Medical Journal (BMJ) earlier this summer.– Trends in global consumption of cigarettes haven’t improved since the World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC) came into force, according to a
Perhaps this is because the FCTC on its own is not a magic bullet. Governments have paid the issue of tobacco-use a lot of lip service but they have invested very little to match the global burden of the epidemic.
Simply agreeing on what needs to be done (i.e. negotiating and ratifying the FCTC) will not on its own lead to reductions in tobacco use. What’s important is whether countries are adopting, implementing and enforcing tobacco control laws and policies in line with their obligations under the treaty.
Tobacco control policies work when implemented, and one of the key lessons to take from the study in the BMJ is that countries urgently need support to do so.
Framing the debate on FCTC impact
Among the most quickly and most universally ratified treaties in existence, FCTC has long been hailed as a breakthrough in efforts to protect the world’s citizens and economies from the harmful effects of tobacco use, which remains a leading global cause of preventable death.
The FCTC has also been looked to as a testing ground for new approaches to global health governance; a potentially replicable model that could be applied to address other health and development issues.
The value and importance of the FCTC and the usefulness of the efforts of the large global tobacco control community that has worked for many years to negotiate the treaty and later to support its ratification and implementation around the world are widely acknowledged.
Much less is known, however, about the impact of the FCTC on smoking patterns.
But what is most needed is a nuanced understanding of how the FCTC impacts cigarette smoking patterns in different regions of the world and the contribution of the treaty to tobacco control policy development and implementation.
We know, indisputably, that tobacco control policies work when implemented, but we also know from experience that implementation and enforcement of these policies is a major challenge in many low- and middle-income countries (LMICs).
These countries often lack the data, organisational structures, human resources, and funds necessary to develop sustainable national tobacco control programmes.
Oiling the wheels of progress
Funding is perhaps the biggest challenge in most LMICs. A 2011 report by the World Health Organization notes that public spending on tobacco control in LMICs ranged from just US$0.0048 to US$0.01 per capita – far short of the estimated per capita cost of US$0.11 required to implement effective tobacco control programs in most LMICs.
There has also been a shocking lack of international investment in tobacco control – amounting to just US$70 million in Development Assistance for Health (DAH) in 2017 according to the Institute of Health Metrics and Evaluation’s most recent report. That’s just 8.5% of all DAH allocated for non-communicable diseases, and an even tinier fraction of all DAH.
The new analysis in the BMJ of the FCTC’s impact since its adoption should serve as an urgent call to action for the international community. Tobacco use causes more than 8 million deaths compared to approximately 3 million deaths for malaria, HIV/AIDS and tuberculosis combined.
Progress on reducing global tobacco use requires a concentrated effort on strengthening FCTC implementation in LMICs. Despite the growing evidence that accelerating FCTC implementation contributes to progress in decreasing tobacco use, too many countries are still lagging behind and failing to invest in tobacco control.
Understanding the priorities and accelerating progress
The newly adopted Global Strategy to Accelerate Tobacco Control identifies specific areas where governments can focus action to create the most impact. Immediate priorities include strengthening national tobacco control plans and adopting stronger price and tax measures.
Raising tobacco taxes to increase tobacco product price and decrease affordability is a particularly compelling policy proposal. A 10% increase in price yields a 4% decrease in consumption in high-income countries and a 5% decrease elsewhere, and the best way for governments to influence prices is to substantially increase taxes.
This is the case in the European Union (EU), where new evidence published in the Tobacco Control journal suggests that high cigarette prices are extremely effective in decreasing cigarette consumption and contributing to public health.
A conclusion that is in line with the new FCTC impact analysis in the BMJ, which points out that some of the difference in consumption trends between high- and low-income countries may be due to the effects of “EU accession rules requiring stringent tobacco control measures among new members”.
Taking a whole- of-government approach
Tobacco use is one of the most challenging health issues that modern societies face. Trying to understand what this challenge means for low- and middle-income countries is crucial. Equally important is to understand that the full and immediate implementation of the FCTC reduces tobacco use.
In just a few weeks, developed and developing countries will meet in New York to review progress on the Sustainable Development Goals (SDGs). Countries cannot afford to overlook the tobacco epidemic and how tobacco control efforts captured under SDG 3.a – though critically under-resourced – are contributing to decreasing tobacco use.
In LMICs, in addition to civil society stakeholders, various government sectors (not only health) must have equal responsibility for ensuring full and effective FCTC implementation. In fact, Article 5 of the treaty addresses tobacco control governance considerations with a view to encouraging robust multi-sectoral mechanisms and protection of tobacco control policies from the commercial and other vested interests of the tobacco industry.
Making the public health case for FCTC implementation is not enough. An economic case can also be made, for instance. The total global economic cost of smoking was estimated to have been US$1.4 trillion in 2012.
This economic burden is particularly damaging for LMICs, who already lack economic resources for development; in 2012, LMICs shouldered 40% of the total economic cost. A multi-faceted approach is vital for LMICs because country delegations to international negotiations such as the upcoming SDG Summit typically comprise representatives of Departments of finance, trade, agriculture and other sectors.
For sustainable development, there is much to be done. There will be little progress if there is no urgent action to reduce tobacco use in LMICs. It’s time for the international community to match the scale of the tobacco use problem with the resources and financing needed to enable progress.