Smouldering progress in tobacco control

Abstract

The State of Tobacco Control 2016, the report of progress towards tobacco control in the USA published by the American Lung Association last week, showed a mixed picture. The report, which tracks yearly progress on key tobacco control policies, found that only one state, Minnesota, scored an A for access to smoking cessation services. Apart from the notable exceptions of North Dakota and Alaska, spending on programmes to prevent and reduce tobacco use was poor throughout the USA. Although substantial progress has been made in reductions in cigarette smoking in young people—rates of smoking in high school students fell by almost 42% since 2011—almost a quarter of high school students reported using at least one tobacco product, and 50% of these used two or more. Last week, WHO called on governments to implement ratings for films that show people using tobacco, in an attempt to reduce the numbers of children who take up smoking. The WHO Framework Convention on Tobacco Control (FCTC), the first global public health treaty, which came into force in February, 2005, binds its signatories by international law to ban tobacco advertising, promotion, and sponsorship, yet film remains a potent way of exposing young people to images of smoking without restrictions. The US Centers for Disease Control and Prevention calculated that exposure to smoking on screen would encourage more than 6 million young people to start smoking in 2014, of whom 2 million would die of tobacco-related causes; in the same year tobacco smoking was shown in 44% of all Hollywood films, and 36% of films rated suitable for young people. The WHO report also criticised Germany, the UK, Poland, the Netherlands, Italy, and Mexico for showing tobacco use in films deemed suitable for children—and found that films from Iceland and Argentina had smoking scenes in nine of ten movies rated suitable for young people. Positive notes come from India—which has put in place new rules on imagery and brand display of tobacco products for domestic and imported films and TV programmes—and China, where it has been ordered that “excessive” smoking should not be shown in films. This might seem like a tiny step for the country where more than a third of the world's cigarettes are smoked, and, as research from Zhengming Chen and colleagues published in The Lancet last year suggests, smoking will cause 20% of all male deaths this decade and the mortality rate ratio will continue to rise—but it is a step. Last year, China raised its consumption tax on the wholesale price of cigarettes from 5% to 11%, and banned smoking in most public places in Beijing; discussions about rolling out the ban nationwide are underway. Smoke-free air laws is one area in which the USA does well. In the American Lung Association's latest report 24 states scored an A and a further seven a B grade in this section, which is very welcome news. A Cochrane Review also published last week showed positive improvements in public health after the introduction of smoking bans, both from reductions in the number of non-smokers being exposed to second-hand smoke, and the provision of supportive environments for smokers who want to quit. Although the Review did not find clear evidence of effects of smoking bans on respiratory health, the health of newborn babies, or reductions in the number of people who smoke or the amount that they smoked, it did find evidence for reduced numbers of hospital admissions due to acute coronary syndromes, and, importantly, for reduced mortality from illnesses related to smoking at a national level. In the Tobacco-free world Series published in The Lancet last year, Robert Beaglehole and colleagues called for “a turbo-charged approach” to reduce tobacco consumption to less than 5% of the world's adult population by 2040, complementing FCTC actions with strengthened UN leadership, full engagement of all sectors, and increased investment in tobacco control, but the world is a long way away from achieving even the bare minimum when it comes to reduction of tobacco consumption. Although Ireland was the first country to mandate smoke-free workplaces nationwide as long ago as 2004, Germany still has no national smoke-free legislation, and in Austria smoking in the workplace is permitted if no employee working in the enclosed space objects. This is not good enough. It is time all Parties to the FCTC protected their citizens by implementing the measures they signed up to more than a decade ago. For Contrasting male and female trends in tobacco-attributed mortality in China: evidence from successive nationwide prospective cohort studies see Articles Lancet 2015; 386: 1447–56 For Contrasting male and female trends in tobacco-attributed mortality in China: evidence from successive nationwide prospective cohort studies see Articles Lancet 2015; 386: 1447–56