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There have been momentous events in tobacco control since the first edition of Tobacco Control was launched in 1992. These include increased global awareness of the harmfulness of tobacco and the WHO Framework Convention on Tobacco Control (WHO FCTC).1 The WHO FCTC represents the most momentous milestone; it was the first treaty negotiated under the auspices of the WHO and entered into force in 2005. It is one of the most rapidly embraced UN treaties and represents a paradigm shift in developing a regulatory strategy to address addictive substances. In contrast to previous drug control treaties, the WHO FCTC asserted the importance of demand reduction strategies as well as supply issues and thus established a framework for an integrated multisectoral response to a grave public health issue.
Other major achievements include strengthening of the international non-governmental movement against tobacco, for example, continuing and expanded world conferences on tobacco or health; the establishment of the International Network of Women Against Tobacco, inaugurated about the same time as the launch of the journal; the Framework Convention Alliance formed in 1999; international web-based networks on tobacco. There has been a significant increase in research on the effects of tobacco and secondhand smoke, the economic costs of tobacco and the behaviour of the tobacco companies; financial contributions of major international donors have increased the levels of funding for tobacco control efforts in low- and middle-income countries. Other key developments include the series of WHO Reports on the Global Tobacco Epidemic,2 which provides an unprecedented level of detail and roadmaps for effective solutions; reduction in smoking prevalence rates in many parts of the world; and the UN summit on Noncommunicable Diseases (NCDs) in 2011, in which the need to address tobacco use prevalence was highlighted as a cornerstone of NCD interventions. That said, the past 20 years have also brought an increasing resistance to tobacco control measures and emerging threats to public health by the tobacco industry, a phenomenon requiring a worldwide coordinated response in order to sufficiently and effectively curb the global tobacco epidemic.
Reductions in prevalence
Strong and sustained action by the international, national and subnational tobacco control communities has led to countless achievements in tobacco control across the globe. Several high- and middle-income countries have achieved substantial reductions in tobacco prevalence rates owing to the development and implementation of targeted and comprehensive national tobacco control strategies. Australia's current smoking rate declined from a 1980 high of 41% among men and 29% among women to 20% and 16%, respectively, in 2010. Turkey's rates have fallen from 50% and 19% among men and women, respectively, in 2003 to 48% for men and 15% for women in 2008; Uruguay has also observed a decline in smoking prevalence rates from a 2003 level of 39% among men and 28% among women to a 2009 level of 31% among men and 20% among women.
Implementation of cost-effective measures to reduce the demand for tobacco
There is robust evidence that tobacco control is cost-effective compared with other health interventions. The evidence base on what works to reduce harm from tobacco provided the foundation for the WHO FCTC. The 1999 book Curbing the Epidemic,3 a landmark World Bank publication, addressed the economic costs of tobacco and estimated the overall impact of tobacco control interventions. Key cost-effective interventions include tobacco tax increases, timely dissemination of information about the health risks of smoking, restrictions on smoking in public places and workplaces, and comprehensive bans on advertising and promotion. These are each considered best buys in reducing tobacco use and preventing NCDs. All these interventions reduce social acceptance of tobacco use, thereby increasing demand for cessation therapies. In this context, it is a good buy to provide smokers in particular and tobacco users in general with treatment for tobacco dependence. Countries that have implemented these measures at the highest level of achievements, such as those listed in the previous section, have been able to effectively reduce the prevalence of tobacco use.
Recognising the need to advance these cost effective measures and to help countries fulfil some of their WHO FCTC obligations, WHO introduced in 2008 the ‘MPOWER’ package of six evidence-based tobacco control demand reduction measures:4
Monitor tobacco use and prevention policies
Protect people from tobacco smoke
Offer help to quit tobacco use
Warn about the dangers of tobacco
Enforce bans on tobacco advertising, promotion and sponsorship
Raise taxes on tobacco.
According to data from the latest WHO Report on the Global Tobacco Epidemic,2 table 1 lists the countries that have put in place the highest number of MPOWER measures at the highest level of achievement. The governments that introduced these strong tobacco control measures represent a range of economic levels and political structures. Thus, an array of countries across the socioeconomic spectrum have exercised their authority to regulate tobacco in view of a legitimate public health objective.
Challenges: the tobacco industry as a vector of an epidemic
Despite the unparalleled successes witnessed over the past 20 years in tobacco control, tobacco industry attempts to impede tobacco regulation have not abated. Epidemiological projections concerning tobacco prevalence suggest that the epidemic will continue to grow at alarming rates if the implementation of effective tobacco control interventions is not intensified. The tobacco industry, as the primary vector of the epidemic, is poised to exploit every avenue it deems viable while reorienting itself in response to any attempt to limit its scope.
From the perspective of communicable diseases, pathogenic capacity to mutate and develop resistance to targeted pharmacotherapies or environmental conditions is of great concern for the public health community. Moreover, vector-borne disease control strategies often target the transmitters of disease-causing organisms. In a similar way, yet with unique characteristics, the tobacco industry's mutative processes reflect the tobacco industry's primary role as the sole vector of the leading preventable cause of death in the world today.
The tobacco industry has traditionally employed a spectrum of deceitful practices to derail tobacco control and undermine public health. These practices are well documented, and the global tobacco control community continues to witness the tobacco industry's persistent use of the same genus of interference strategies in countries where tobacco control is still in its nascency. Traditional tobacco industry actions include the leveraging of monetary and political influence, vehement opposition to, and circumvention of, the development and implementation of effective tobacco control legislation, the undermining of scientific evidence and the introduction of disingenuous Corporate Social Responsibility (CSR) programmes. These practices represent a fraction of the array of strategies that the tobacco industry continuously uses to impair public health in countries vulnerable to industry exploitation.
With the advent of the WHO FCTC and the advancement by an increasing number of countries of the implementation of the evidence-based tobacco control policies enshrined therein (see table 1), the tobacco industry has sought novel strategies to sustain its propagation of death and disease. Not unlike drug-resistant strains of biological pathogens, tobacco companies have begun to mutate and adapt with a view of incorporating a new aggressive genetic blueprint in response to effective tobacco control. This calculated metamorphosis not only includes a repackaging of interference practices that, for example, exploit untapped marketing avenues, new technologies and social media, but also introduce novel and unseen tactics that elevate the degree and profile of industry interference.
As an example of these inventive strategies, the recent slate of international legal challenges launched by tobacco companies in opposition to the implementation of legitimate, robust and landmark tobacco control measures signifies the depth to which the industry will descend in order to expand market share at the expense of public health. The international commercial arbitration challenges launched against Uruguay and Australia on the basis of bilateral investment treaties typify the tobacco industry's response to countries exercising their regulatory autonomy in the tobacco space: one of untenable intimidation.
The UN high-level meeting on the prevention and control of NCDs
The UN high-level meeting on NCDs in September 2011 in New York is illustrative of the type of opportunity and political climate that currently exists to ensure that the global public health community and governments are able to consolidate their response to burgeoning industry tactics. As the tobacco industry continues to heighten its barrage on public health, the NCD Summit, which represented only the second time in the history of the UN that the General Assembly convened on a health-related issue (the last meeting related to health was held in 2001 and was targeted at HIV/AIDS, leading to the creation of The Global Fund to Fight AIDS, Tuberculosis and Malaria), highlighted the impact of tobacco and NCDs on both public health and country economies. There, the UN General Assembly, comprised of heads of state and many ministers, adopted a political declaration wherein member states unanimously committed to advancing the implementation of multisectoral, cost-effective, population-wide interventions in order to reduce the impact of NCD risk factors. Given the global support expressed in September 2011, the time is ripe for effective translation of this political declaration into international cooperation and action in protecting the regulatory autonomy of countries with a view to the public interest from the tobacco industry.
WHO and public health advocates consider the tobacco industry vector an NCD emergency which requires coordinated and decisive action: the WHO FCTC Conference of Parties adopted the Punta del Este Declaration in 2010 in support of WHO FCTC parties who are facing legal attacks for implementing the treaty and its guidelines5; WHO has made the interference of the tobacco industry with public health the theme of the 2012 World No Tobacco Day; and the 4th edition of The Tobacco Atlas (2012) will expose legal challenges by the tobacco industry as well as the industry's ‘undue influence’ in countries.
We agree with the views of Callard and Collishaw6 published in this edition, who stress the need to more efficiently monitor and resist the tobacco industry vector. It is imperative that the public health community continues to uncover and highlight the disingenuous nature of tobacco companies, and that countries accelerate the implementation of Article 5.3 of the WHO FCTC which explicitly recognises the need to protect tobacco control from commercial and other vested interests of the tobacco industry. The irreconcilable conflict between the tobacco industry's interests and those of public health is acknowledged in the Guidelines for Implementation of Article 5.3 of the WHO FCTC and was also recognised by the UN General Assembly at the high-level meeting on NCDs in September 2011. This global reiteration of the tobacco industry's escalating attacks on public health serves to crystallise the point that the tobacco epidemic cannot be addressed unless health policy development and implementation is simultaneously insulated from the tobacco industry.
Competing interests The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or the policies of the World Health Organization.
Provenance and peer review Commissioned; internally peer reviewed.