WHO reports progress in the fight against tobacco epidemic

Many countries are making progress in the fight against tobacco, but a new World Health Organization report shows some are not addressing emerging nicotine and tobacco products and failing to regulate them.

Increased adoption of WHO-recommended tobacco control measures

More than four times as many people are now covered by at least one WHO-recommended  tobacco control measure as compared with 2007. The six MPOWER measures are monitoring tobacco use and preventive measures; protecting people from tobacco smoke; offering help to quit; warning about the dangers of tobacco; enforcing bans on advertising, promotion and sponsorship; and raising taxes on tobacco.

Some 5.3 billion people are now covered by at least one of these measures – more than four times the 1 billion who were covered in 2007.

More than half of all countries and half the world’s population are now covered by at least two MPOWER measures at the highest level of achievement. This reflects an increase of 14 countries and almost one billion more people since the last report in 2019.

More than half of the world’s population are exposed to tobacco products with graphic health warnings.  However, progress has not been even across all MPOWER measures. Some measures like raising tobacco taxes have been slow to move and 49 countries remain without any MPOWER measures adopted.

Need to tackle threats posed by new nicotine and tobacco products

For the first time, the 2021 report presents new data on electronic nicotine delivery systems, such as ‘e-cigarettes’. These products are often marketed to children and adolescents by the tobacco and related industries that manufacture them, using thousands of appealing flavours and misleading claims about the products.

WHO is concerned that children who use these products are up to three times more likely to use tobacco products in the future.  The Organization recommends governments to implement regulations to stop non-smokers from starting to use them, to prevent renormalization of smoking in the community, and to protect future generations.

“Nicotine is highly addictive. Electronic nicotine delivery systems are harmful, and must be better regulated,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General, “Where they are not banned, governments should adopt appropriate policies to protect their populations from the harms of electronic nicotine delivery systems, and to prevent their uptake by children, adolescents and other vulnerable groups.”

84 countries lack safe-guards to protect from unregulated proliferation of electronic nicotine delivery systems

Currently, 32 countries have banned the sale of electronic nicotine delivery systems (ENDS). A further 79 have adopted at least one partial measure to prohibit the use of these products in public places, prohibit their advertising, promotion and sponsorship or require the display of health warnings on packaging. This still leaves 84 countries where they are not regulated or restricted in any way.

Michael R. Bloomberg, WHO Global Ambassador for Noncommunicable Diseases and Injuries and founder of Bloomberg Philanthropies, said “More than 1 billion people around the world still smoke. And as cigarette sales have fallen, tobacco companies have been aggressively marketing new products – like e-cigarettes and heated-tobacco products – and lobbied governments to limit their regulation. Their goal is simple: to hook another generation on nicotine. We can’t let that happen.”

Dr Rüdiger Krech, Director of the Health Promotion Department at WHO, highlighted the challenges associated with their regulation. “These products are hugely diverse and are evolving rapidly. Some are modifiable by the user so that nicotine concentration and risk levels are difficult to regulate. Others are marketed as ‘nicotine-free’ but, when tested, are often found to contain the addictive ingredient. Distinguishing the nicotine-containing products from the non-nicotine, or even from some tobacco-containing products, can be almost impossible. This is just one way the industry subverts and undermines tobacco control measures.”

The proportion of people using tobacco has declined in most countries, but population growth means the total number of people smoking has remained stubbornly high. Currently, of the estimated 1 billion smokers globally, around 80% of whom live in low- and middle-income countries (LMICs). Tobacco is responsible for the death of 8 million people a year, including 1 million from second-hand smoke.

While ENDS should be regulated to maximize protection of public health, tobacco control must remain focused on reducing tobacco use globally. MPOWER and other regulatory measures can be applied to ENDS.

Editor’s note:

The eighth WHO Report on the global tobacco epidemic launched today summarizes national efforts to implement the most effective demand reduction measures from the WHO Framework Convention on Tobacco Control (WHO FCTC) that are proven to reduce tobacco use. These measures are known collectively as “MPOWER”.

The MPOWER interventions, have been shown to save lives and reduce costs from averted healthcare expenditure. The first MPOWER report was launched in 2008 to promote government action on six tobacco control strategies in-line with the WHO FCTC to:

• Monitor tobacco use and prevention policies.
• Protect people from tobacco smoke.
• Offer help to quit tobacco use.
• Warn people about the dangers of tobacco.
• Enforce bans on tobacco advertising, promotion and sponsorship.
• Raise taxes on tobacco.

The WHO report on the global tobacco epidemic, 2021, finds that:

• Since 2007, 104 countries have introduced one or more MPOWER measures at the highest level of achievement.
• More than half of all countries are now covered by graphic health warnings on tobacco packaging at best-practice level
• While being the most effective way to reduce tobacco use, taxation is still the MPOWER policy with the lowest population coverage and has not increased from the 14% achieved in 2018.
• Of the 5.3 billion people protected by at least one MPOWER measure, over 4 billion live in low- and middle-income countries (LMICs) (or 65% of all people in LMICs).
• 49 countries have yet to adopt a single MPOWER measure at the highest level of achievement – 41 are LMICs.
• In the world’s 29 low-income countries, 15 today have at least one MPOWER policy in place at best-practice level compared to three in 2007, showing that income level is not a barrier to best-practice tobacco control
• Most high income countries (HICs) (78%) regulate ENDS, and 7% have a ban on sales without any other regulation. Among MICs, 40% regulate ENDS, and 10% have a ban on sales without any other regulation, leaving half of middle income countries (MICs) neither regulating ENDS nor banning their sale. In contrast, 76% of LICs neither regulate ENDS nor ban their sale.

For each MPOWER measure, there have been new countries that have implemented some of the measures at the best practice level since the last report:

• Five countries (Bolivia, Ethiopia, Jordan, Paraguay, Saint Lucia) newly adopted complete smoke-free laws covering all indoor public places, workplaces and public transport.
• Five countries (Austria, Cook Islands, Jordan, Philippines, Tonga) advanced to best-practice level with their tobacco use cessation services. However, during the same period, three other countries dropped from the highest group, resulting in a net gain of only two countries.543
• Eight countries (Ethiopia, Gambia, Mauritania, Montenegro, Niger, Nigeria, Qatar, United States of America) adopted large graphic pack warnings.
• Five countries (Cote d’Ivoire, Ethiopia, Iraq, Jordan, Venezuela (Bolivarian Republic of)) introduced comprehensive bans on tobacco advertising, promotion and sponsorship (TAPS), including at point-of-sale.
• Six countries (Denmark, Georgia, Morocco, Netherlands, Portugal, Sri Lanka) moved to the best-practice group by levying taxes that comprise at least 75% of retail prices.