Impact of the WHO Framework Convention on Tobacco Control on global cigarette consumption: quasi-experimental evaluations using interrupted time series analysis and in-sample forecast event modelling

July 16, 2019

We welcome Hoffman (1) et al’s evaluation of the impact of the Framework Convention on Tobacco Control (FCTC) on tobacco consumption.

We agree with their overall conclusions and highlight a few issues that the authors did not fully address. First, they did not stress the long term value of international treaties; second, they failed to recognize the global need to do far more to end smoking among the 1.3 billion tobacco users worldwide; and third, they did not mention the importance of adapting FCTC provisions derived from the experiences of mainly Organization for Economic Cooperation and Economic Development (OECD) countries to the different realities of developing countries (2).

The FCTC process started with the first WHO resolution in 1970 (3) and was built on consensus achieved over the next three decades. That process matters. It placed tobacco control at the center of efforts to address all noncommunicable diseases (NCDs) at a time when global health was equated with infectious diseases and undernutrition. The fears of complacency as expressed by Hoffman and Yach (4) are evident with media and governments believing that with adoption of the FCTC, the job is done.

MPOWER (5) has focused efforts on a few major interventions. All are important but only a focus on cessation and harm reduction will bring death and disease rates down inside 2 to 3 decades. We owe it to the 1.3 billion smokers, many with comorbid conditions (from schizophrenia to tuberculosis, heart, and lung diseases), to do more in this area. WHO acknowledges that progress on cessation has been slow (6), and our work shows that there is an innovation gap demanding to be filled for better and more affordable cessation (7). While the evidence grows about the substantial potential benefits of tobacco harm reduction, WHO has yet to move harm reduction from the FCTC preamble into action (8)

Most early adopters of tobacco control were advanced industrialized countries with well-developed legal systems to design and enforce laws. The reality is that for countries where Hoffman and colleagues highlight the greatest increases in tobacco use, tobacco generates significant tax revenues and economies still rely on tobacco production, manufacturing, and trade; grassroots of tobacco control movement is slow; legal regimes are weak; and several basic provisions of the FCTC simply fail (e.g., large pictorial health warnings on cigarette packs in India where cigarettes are sold singularly, higher tax rates on cigarettes [82%] in Turkey where illicit trade is problematic).

Bauld (9) is correct to stress the need to fully implement several FCTC provisions but more of the same will simply not lead to the decreased consumption levels required under the UN’s Sustainable Development Goals. Failure to meet these undermines the achievement of many NCD goals.10 What is required is new energy and new funding directed to developing countries as well as innovations in accelerating cessation and harm reduction in ways supported by regulations.

Declaration of Interest

Dr. Derek Yach, a global health expert and anti-smoking advocate for more than 30 years, is the President of the Foundation for a Smoke-Free World (FSFW), an independent, US nonprofit 501(c)(3) organization with the purpose of improving global health by ending smoking in this generation. Dr. Yach is a former World Health Organization (WHO) Cabinet Director and Executive Director for noncommunicable diseases and mental health where he was deeply involved with the development of the world’s treaty on tobacco control, the Framework Convention on Tobacco Control (FCTC).

Dr. Ehsan Latif is Vice President of Grant Management and Development at FSFW. He has been involved in tobacco control efforts for almost two decades, including with the development of the FCTC. Dr. Latif has served on the Boards for international coalitions, including the Framework Convention Alliance and Non-Communicable Disease Alliance.

Dr. Ayda A. Yurekli is the Principal Economist at FSFW. She has worked on economics of tobacco control and taxation issues for over 20 years, including roles at the US Centers of Disease Control and Prevention, the World Bank and WHO.

The Foundation for a Smoke-Free World has received contributions from Philip Morris International (PMI) in 2018 and 2019 each in the amount of US$80 million. PMI has pledged to contribute $80 million annually for the next ten years. Under the Foundation’s Bylaws and Pledge Agreement, PMI and the tobacco industry, generally, are precluded from having any control or influence over how the Foundation spends its funds or focuses its activities.

References
1 Hoffman SJ, Mathieu JPP, Van Katwyk SR, Baral P, Sritharan L. Impact of the WHO Framework Convention on Tobacco Control on global cigarette consumption: quasi-experimental evaluations using interrupted time series analysis and in-sample forecast event modelling. BMJ. 2019;365:12287. https://www.bmj.com/content/365/bmj.l2287

2 Hoffman SJ, Tan C. Overview of systematic reviews on the health-related effects of government tobacco control policies. BMC Public Health. 2015; 15:744. https://doi.org/10.1186/s12889-015-2041-6.

3 Yach D. The origins, development, effects, and future of the WHO Framework Convention on Tobacco Control: a personal perspective. The Lancet. 2014: 383; 9930. https://doi.org/10.1016/S0140-6736(13)62155-8 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62155-8/fulltext

4 Yach D. Injecting greater urgency into global tobacco control. Tobacco Control. 2005;14:145-148 http://dx.doi.org/10.1136/tc.2005.011957.

5 WHO (2008), World Health Organization- New Report on global tobacco control efforts. WHO news release, February 7, 2008. https://www.who.int/mediacentre/news/releases/2008/pr04/en/ , and https://www.who.int/tobacco/mpower/en/

6 World Health Organization. WHO report on the global tobacco epidemic 2017. https://apps.who.int/iris/bitstream/handle/10665/255874/9789241512824eng.... Accessed July 16, 2019.

7 Chung-Hall J, Craig L, Gravely S, Sansone N, Fong GT. Impact of the WHO FCTC over the first decade: a global evidence review prepared for the Impact Assessment Expert Group. Tobacco Control. 2018; 0:1-10. http://dx.doi.org/10.1136/tobaccocontrol-2018-054389.

8 Collishaw N. This should change everything: using the toxic profile of heat-not-burn products as a performance standard to phase out combustible cigarettes. BMJ. 2017: 28:3. https://tobaccocontrol.bmj.com/content/28/3/245

9 Bauld L. Tobacco Control: New Resources, Existing Treaties, and Emerging challenges. BMJ. 2019: 365: l4161. https://doi.org/10.1136/bmj.l4161.

10 Foundation for a Smoke-Free World. Mapping to the Sustainable Development Goals. https://www.smokefreeworld.org/sites/default/files/uploads/documents/fsf.... Accessed July 16, 2019.