Progress towards a tobacco-free world

Abstract

Last week, global anti-smoking efforts made substantial progress. Australia won a landmark victory in a major trade dispute over its plain packaging for cigarettes, with the World Trade Organization panel rejecting complaints concerning its tobacco packaging law. Additionally, the WHO Framework Convention on Tobacco Control (FCTC) announced that the Protocol to Eliminate Illicit Trade in Tobacco Products would enter into force, representing a milestone in providing the legal basis for strengthening the international community's actions in tobacco control. Unprecedented legal actions against tobacco were also reported in China and Japan. On June 25, the Beijing Railway Transport Court ruled that a train operator should remove all designated smoking areas and smoking paraphernalia on its trains after a passenger sued the company over exposure to second-hand smoke. This case was regarded as China's first lawsuit over smoking in public areas and a remarkable victory for the country's anti-smoking activists. On June 27, Japan's capital Tokyo passed a tough anti-smoking law that is stricter than the national version currently under consideration, which will effectively ban smoking in most of the city's bars and restaurants to enable a tobacco-free 2020 Olympics. Scaling up tobacco control with global and national legislation and legal approaches is admirable and a crucial step forward, but such progress does not warrant complacency given the continuing global tobacco epidemic and huge gap in the full implementation of the WHO FCTC in many countries. The Global Burden of Diseases 2015 Tobacco Collaborators reported in The Lancet that the prevalence of daily smoking was 25·0% for men and 5·4% for women, and 11·5% of global deaths were attributable to smoking, of which 52·2% occurred in four countries (China, India, the USA, and Russia). Despite the fall in prevalence since 1990, the actual number of smokers continues to increase worldwide owing to population growth. Furthermore, disease burden associated with smoking is expected to increase, in low-income and middle-income countries in particular, driven by demographic forces including population ageing. Implementation of key WHO FCTC demand-reduction measures was associated with lower smoking prevalence, with anticipated future reductions in tobacco-related morbidity and mortality, as requested by Shannon Gravely and colleagues in The Lancet Public Health in 2017. However, more than a decade since its adoption, implementation of the global treaty has been slow and uneven, in large part because of tobacco industry interference with governments' efforts to deliver tobacco control policies. Australia's victory in tobacco plain packaging does not mean that the war against the tobacco industry is over. Instead, intensified action in monitoring the tobacco industry and exposing its conduct is necessary to sustain the progress made so far. One area not yet fully realised is the potential contribution of health-care services in tobacco control. The latest report, Hiding in plain sight: Treating tobacco dependency in the NHS, released by the UK's Royal College of Physicians (RCP) on June 26, argues that the policies and practices that should have helped patients who smoke to quit have singularly failed. The RCP proposes that the National Health Service should deliver default and opt-out interventions to treat their addiction for all smokers at the point of service contact. Although this report is directed towards the UK, the overall message is relevant globally: tobacco dependence should be treated routinely, and smoking prevention and treatment should become core activities for all health professionals and services. As the report rightly points out, “Failure to identify and treat smokers is no less negligent than failure to identify and treat patients with cancer. Systems failure is no less negligent in this respect than individual failure.” In 2015, at the 10-year anniversary of the coming into force of the FCTC, The Lancet supported a campaign to achieve a tobacco-free world by 2040—where less than 5% of the world's adult population use tobacco. Achieving this goal will require a turbo-charged approach that complements FCTC actions with strengthened UN leadership, full engagement of all sectors, and increased investment in tobacco control. The legal success in Australia, together with the positive action taken in other countries last week, show that ambitious targets are achievable if political will remains strong at the global, regional, and national levels. Progress towards a tobacco-free world can be accelerated much more with the full commitment of all stakeholders, from governments to health-care services, and especially health professionals.