The power of a treaty

Abstract

According to WHO, about 6 million people die from tobacco use every year, and this is estimated to increase to more than 8 million a year by 2030 without intensified action. Against this predicament, public health is not unarmed. In response to the globalisation of the tobacco epidemic, the WHO Framework Convention on Tobacco Control (WHO FCTC)—the first international treaty negotiated under the auspices of WHO—was adopted in 2003, and entered into force in 2005. For WHO, the Convention represents “a milestone for the promotion of public health and provides new legal dimensions for international health cooperation.” It certainly does. But does it work? A decade later—it is time to assess the power of this treaty. To answer this question, Shannon Gravely and colleagues examined the association between implementation of key tobacco control measures of the WHO FCTC and smoking prevalence in 126 countries. More precisely, in their study published in The Lancet Public Health, they looked at the association between the change in countries' implementation of five key measures (increased taxes on tobacco products; protection of people from tobacco smoke; health warnings; enforcement of bans on tobacco advertising, promotion, and sponsorship; and cessation aid) and the change in smoking prevalence in those countries from 2005 to 2015. Their results are clear: countries' implementation of these key measures is associated with a decrease in smoking. Importantly, the more interventions, the larger the effect: overall, each additional measure implemented at the highest level was associated with a reduction in smoking prevalence of 1·57%. On average, smoking rates across all 126 countries went down from 24·7% in 2005 to 22·2% in 2015. These results are important because they show the potential of tobacco control measures to reduce tobacco use, they do validate the importance of such treaty and the public health impact it can have in countries. Still, with an average decrease of 2·5 percentage points over a decade, progress is too small, too slow, and uneven. Only one country in the study had implemented all five key measures at the highest level. When implementing key measures, many governments are facing critics portending to a so-called nanny state in which the government is thought to unnecessarily control people's freedom of choice. Only a fifth of countries had implemented tax measures at the highest level, while raising tobacco taxes to increase prices is the most effective way of reducing tobacco use. Smoking prevalence decreased in 71 countries, but worryingly, did not change in 12 countries and increased in 24 countries. Increases in tobacco prevalence are expected in some parts of the world, in particular in developing countries in Africa. Tobacco control needs to be firmly anchored in the Sustainable Development Goals (SDGs). It is one of the most effective ways to achieve SDG 3 and its target of a one-third reduction of premature deaths from non-communicable diseases—including cardiovascular disease, cancers, and pulmonary disease, by 2030. From April, the FCTC 2030 project will support WHO FCTC Parties that are eligible to receive official development assistance to achieve the SDGs by advancing implementation of the FCTC. The project will provide extra technical support to aid governments in developing countries to advance tobacco control. It aims to address the drastic disparities between countries with many low-income and middle-income countries struggling under the weight of the tobacco epidemic. Control of the tobacco epidemic is essential for countries worldwide. Not only can it have devastating health consequences but also the tobacco epidemic costs countries' economies enormously through increased health-care costs and decreased productivity. “Tobacco—a threat to development” will be the theme of this year's World No Tobacco Day on May 31. The campaign aims to “demonstrate the threats that the tobacco industry poses to the sustainable development of all countries, including the health and economic well-being of their citizens”. Tobacco control is not only at the mercy of one country's laws. Complex global factors such as foreign investment and industry agendas also interplay. What the treaty shows is that when there is political will those forces can be overcome. The legacy of the WHO FCTC fosters further collaboration between countries and holds the promise of improvements in public health. Understanding the association between the WHO Framework Convention on Tobacco Control, adoption of tobacco control policies, and reduction in smoking prevalenceGiven the public health significance of tobacco use and the potential of the WHO Framework Convention on Tobacco Control (FCTC), the world's first global health treaty, to diminish its toll, it is important to understand the treaty's impacts and to learn how to accelerate adoption of effective policy interventions. As such, the Article by Shannon Gravely and colleagues1 represents a welcome addition to the research literature on tobacco control. The authors' analysis assesses policy from a so-called 30 000-foot perspective, giving the most general level view: it examines the association between the change from 2007 to 2014 in countries' implementation of five key FCTC tobacco demand-reduction measures and the change from 2005 to 2015 in smoking prevalence in those countries. Full-Text PDF Open AccessImplementation of key demand-reduction measures of the WHO Framework Convention on Tobacco Control and change in smoking prevalence in 126 countries: an association studyImplementation of key WHO FCTC demand-reduction measures is significantly associated with lower smoking prevalence, with anticipated future reductions in tobacco-related morbidity and mortality. These findings validate the call for strong implementation of the WHO FCTC in the WHO's Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013–2020, and in advancing the UN's Sustainable Development Goal 3, setting a global target of reducing tobacco use and premature mortality from non-communicable diseases by a third by 2030. Full-Text PDF Open AccessTobacco control in the Sustainable Development Goals: a precarious inclusion?The Lancet Public Health editorial in April, 2017, called for tobacco control to be “firmly anchored in the Sustainable Development Goals (SDGs)”.1 As development practitioners, we are cognisant that governments face tough resourcing and implementation decisions to achieve this ambitious agenda (17 goals and 169 targets). Despite inclusion of a specific target for implementation of the WHO Framework Convention on Tobacco Control (FCTC; target 3.a), there is a risk that tobacco control will remain a focus for the health community only. Full-Text PDF Open Access