Ahmed Yousif Ali*
National Rehabilitation Center, Abu Dhabi, UAE
Visit for more related articles at International Journal of Emergency Mental Health and Human Resilience
The WHO is to be congratulated for organizing a most successful event, the 16th “World Conference on Tobacco or Health”, WCTOH, Abu Dhabi, UAE, 17-21 March 2015. The purpose of this paper is to summarize the conference proceedings and highlight the most important conclusions reached and the future directions recommended, in the war on tobacco use.
The WHO is to be congratulated for organizing a most successful event, the 16th “World Conference on Tobacco or Health”, WCTOH, Abu Dhabi, UAE, 17-21 March 2015.
The purpose of this paper is to summarize the conference proceedings and highlight the most important conclusions reached and the future directions recommended, in the war on tobacco use.
The conference celebrated 10 years of the FCTC (Framework Convention of Tobacco Control, 2005-2015) and reported the outcome of MPOWER, the tool assessing corresponding demand reduction FCTC articles performance (MPOWER, 2013). Two top British medical journals, The Lancet and The BMJ group’s Tobacco Control, issued supplements to coincide with the conference, and countries from around the world showcased their achievement and lamented governments’ failures. The presence of academic institutes, civil societies, NGOs, charities (notably The Emirates Cardiac Society, the CDC, Johns Hopkins, Bloomberg Philanthropies and The American Cancer Society) was very salient. Also the 5th Edition of The Tobacco and 2nd of The Cancer Atlases (The Tobacco Atlas, 2015; The Cancer Atlas, 2014) were launched.
Speakers (5 of them country health ministers) kept repeating the Phrase “low hanging fruits’ as they optimistically pointed out opportunities for a tobacco free generation. This Tobacco “Endgame” is defined by a target date and target prevalence in different parts of the world. In an editorial, the lancet went for 2040 as a target and a prevalence of less than 5% (Editorial, 2015). Country examples include, USA declaring this year, their target to reduce the smoking rate to less than 10% for both youth and adults in 10 years (currently 15.7% and 17.8% respectively) (Beaglehole et al., 2015), Scotland accepts the target prevalence but aims for 2034 (Murthy, 2015), Finland accepts the date but goes for an entirely tobacco free country (Beaglehole et al., 2015), New Zealand is to be free by 2025, while Bhutan banned the sale of all tobacco products in 2004 (Creating A Tobacco-Free Generation, 2013).
In the fight against Tobacco, this conference comes at a critical time as the current MDGs (Millennium Development Goals) expire, this year, to be replaced in September 2015 by the United Nation’s new SDGs (sustainable development Goals) ( ENSP, 2011).
The post-2015 SDGs cover the period 2016-2030.The MDGs background goes back to 2000 and are now criticized for the exclusion of tobacco control and NCDs (non-communicable diseases). This lead to poor engagement and low resource allocation from governments’. The MDGs were mostly intended for LICs (low Income Countries) (Ugen, 2003).
The declared aim of the new SDGs is to eradicate global poverty. The initial exclusions in the MDGs will be avoided, so the full range from low to high income countries will be included in a universal plan.
The working group proposal for the SDGs already show promise in a structured plan. By 2030 the aim is to reduce by one third pre-mature mortality from NCDs and strengthening implementation of FCTC in all countries. (https://sustainabledevelopment.un.org/?page=view&n r=1064&type=13&menu=1300).
The 4 NCDs which kill 38 million humans annually are cardiovascular diseases, cancer, and chronic respiratory diseases and diabetes. They are responsible for 80% of all NCD deaths. There are 4 shared modifiable risk factors which are tobacco use, physical inactivity, harmful use of alcohol and unhealthy diets in the list of the 9 NCD targets. A legitimate question is why other condition like mental illness or renal disease are not included in this group?
There are 9 voluntary global targets prescribed by the WHO for the prevention and control of NCDs to be attained by 2025. The famous motto “25 by 25” comes from the 25 indicators that measure progress in implementation of those 9 targets by 2025. (http://www. who.int/mediacentre/factsheets/fs355/en/)
The global burden of disease caused by tobacco products is very costly being responsible for 100 million deaths in the 20th century. It will reach a billion deaths by the end of this century if serious steps are not taken (FCTC, 2015; The Tobacco Atlas, 2015).
At present the prevalence of daily smoking is variable from unacceptably high of 60% male adults in Russia, to 31% of male adults over 15 down from 41% in the 1980s and 6 % of women down from 11% (Tobacco-free world, 2015).
A tobacco free generation slogan can be a powerful social marketing technique and a unifying motivator. It maximizes consumer engagement and is a great driver for tobacco cessation campaigns. It should be a great spokesperson for the SDGs and NCDs targets of the WHO. However, such a “designer generation” creation will face many challenges like:
• Exposing and resisting the aggressive tactics of the tobacco industry (Editorial, 2015).
• E-Cigarettes, Water pipe smoking, smokeless tobacco products.
• Accelerating progress in China.
We should accept that many authorities consider “Current global anti-tobacco strategies are failing (Editorial, 2015) and should not underestimate the tobacco industry’s retaliation. They are equipped with a trillion dollar net profit per annum to recruit new smokers, especially women and young people to maintain their customer supply (MPOWER, 2013). Still many experts and speakers at the conference identified achievable goals or low hanging fruits on the long road to a Tobacco free generation.
The WHO Framework Convention on Tobacco Control (WHO FCTC) often referred to as a landmark treaty in global health; seem to bear most of these fruits. It is the world’s only legally binding public health tool. It came into force in February 2005, 180 countries have ratified it and 135 have strengthened or adopted new legislations. China and Indonesia are yet to ratify it and progress has been described as slow in LMICS (Editorial, 2015).
The FCTC combines comprehensive measures to decrease public demand for tobacco products with those to reduce their supply. Six evidence based tobacco control measures that are the most effective in reducing tobacco use, abbreviated as MPOWER were introduced by the WHO in 2010 to scale up the implementation of demand reduction provisions included in the FCTC. They stand for, M: Monitor tobacco use and prevention policies, P: Protect from tobacco smoke, O: Offer help to quit tobacco use, W: Warn about the dangers of tobacco, E: Enforce bans on tobacco advertising, promotion and sponsorship and finally R: raise tax on tobacco. WHO succeeded in doubling the population covered through MPOWER from 1 to 2.3 billion, or one third of the world’s population (MPOWER, 2013).
Article 6 of the FCTC, “Price and Tax Measures to Reduce the Demand for Tobacco", addresses most effective approach to controlling the spread of tobacco, the simple elevation of tobacco prices by use of consumption taxes. On average, a 10% price increase on a pack of cigarettes would be expected to reduce demand for cigarettes by about 4% in high-income countries and by about 5% in low- and middle-income countries (FCTC, 2015).
Article 11, FCTC, deals with packaging and labeling stipulating effectively banning misleading and deceptive terms like low tar, mild and ultra-mild products. The principal display areas should carry clear and visible health warning that should be 50 % or more and no less than 30 %. A couple of important documents, for those interested, are the Canadian Cancer Society report on health warnings (Tobacco-free World, 2015) and the pioneering Australian experience in the field (http://www.health.gov.au/internet/main/publishing.nsf/Content/tobacco-warn).
Article 13 requires a comprehensive ban on all forms of Tobacco advertising promotion and sponsorship (TAPs), within 5 years of entry into force of the convention (MPOWER, 2013).
Some incredibly successful models were presented in support of Article 17: the provision of support for economically viable alternatives to tobacco growing that can sustain the livelihoods of tobacco workers, growers and individual sellers, especially from Brazil and Kenya.
Challenges to the FCTC include the modest implementation in LIMCS (Low and Middle Income Countries); many are yet to ratify it or not on-track to achieve their target, with several low and middle-income countries at risk of worsening their tobacco epidemics, notably in Africa and the eastern Mediterranean. The WHO target of a 30% reduction in prevalence of smoking by 2025 will certainly be missed if efforts are not intensified.
Three hot topics that received special attention at the conference were Electronic Nicotine Delivery Systems, aka E-cigarettes, Water pipe smoking and smokeless tobacco.
E-cigarettes have been with us since the 1960s, China is credited with the 2nd generation, 2003, and Britain, the current 3rd generation. They are devices that deliver to the lungs a chemical mixture usually composed of nicotine, Propylene glycol and other substances (Schraufnagel, 2014). There are two camps at present those for and those against ENDS, each defending their corners. The former tend to be governmental, public health and international organizations (WHO and UN are the largest). Those against, tend to be the harm reduction and civil liberties movements and some influential opinion leaders.
The former camp argue there is no evidence they help in smoking cessation efforts or reducing tobacco use, no evidence of safety in the medium or long term. Projections dictate they would exceed combustible cigarettes sales by 2024, if the consumption continues to increase at the current exponential rate.
ENDS use among School age children in the US has tripled since 2011 and 50% of those surveyed (260000) intended to smoke combustible cigarettes in the next year. (http://www.cdc.gov/media/releases/2015/p0416-e-cigarette-use.html).
At least 10 toxicants can be identified and quantified in electronic cigarettes, including known carcinogens like propylene glycol (which is potentially toxic) found in all ENDS samples and tobacco specific N-nitrosamines (powerful carcinogens).
Those speaking for the E-cigs consider them a significant health innovation and insist it is “vaping” and not smoking. 50 researchers wrote to the WHO to caution against over regulation (http://www.reuters.com/article/2014/05/28/health-ecigarettes-idUSL6N0OD3ZE20140528). This camp argues that users are more than 60% likely to quit and could save 6,000 lives per year for every million smokers.
Water pipe smoking has been known for centuries, India & south East Asia seems to be the origin with the Middle East getting involved in the 20th century. The spread at the beginning of the 21st century is attributed to multiple factors among which the spread of café culture in the ME and the introduction of Maasel, flavoring and easy use tobacco (Ward, 2015).
Myths surrounding WP include its safety due to filtering out of tobacco through water. The unregulated industry is accused of tampering with labeling to mislead users about the tar content and many do not bother to put health warning on the packages or the hookah. 82 toxicants have been quantified in the WP tar featuring polyaromatic hydrocarbons, nitrosamines, carbonyl compounds and volatile organic compounds. (For a full and comprehensive review see BMJ Tobacco control supplement referenced below) (Ward, 2015; Maziak, 2015).
Smokeless tobacco featured regularly in the discussions with more than 30 carcinogens identified and sufficient evidence that it causes oral, esophageal and pancreatic cancer in humans.
300 million people around the world are estimated to use these products.
To summarize, a tobacco free generation is in sight and the WHO will need all the help it can get from governmental and non-governmental agencies around the world. A partnership should be forged where :
• Public health authorities fulfill their part.
• NGOs contribute in advocacy, leadership, service delivery, watchdog roles.
• Governments should be held accountable to full implementation of FCTC, achieving the NCD targets of 2025 and implementing the post 2015 agenda.
• Tobacco industry tactics should be scrutinized and measures to prohibit their access to youth and women should be prioritized.
Many of these agencies will be looking for funding the strategies at the international conference on Financing for development in July 2015 when they meet in Ethiopia and we wish them well.
If one is not to pushing the proverbial boundaries too far, we hope the WHO can see the trees for the forest and pick those fruits for all humanity.
Beaglehole, R., Bonita, R., Yach, D., Mackay, J., Reddy, S.K. (2015). A tobacco-free world: a call to action to phase out the sale of tobacco products by 2040. The Lancet, 385(9972), 1011-1018.
Canadian cancer society, cigarette package health warnings, international status report (4thedn). September 2014.Creating A Tobacco-Free Generation: A Tobacco Control Strategy for Scotland (2013). Healthier Scotland, Scottish Government, Edinburgh.
Editorial (2015). What will it take to create a tobacco-free world? The Lancet, 385(9972), 915.
FCTC (2015) 10 Years on, 2005-2015, WHO Framework Convention on Tobacco Control, www.who.int/fctc
Finland smoke free by 2040.Published on ENSP. http://www.ensp.org, 28/06/2011
Maziak, W., Taleb, Z.B., Bahelah, R., Islam, F., Jaber, R., Auf, R., et al. (2015) The global epidemiology of Waterpipe smoking; Tobacco Control, 24,i3-i12.
MPOWER (2013). Fresh and alive, Who Report On TheGlobaltobacco Epidemic.
Murthy, V.H. (2015) Working Toward a Tobacco-Free Generation: 51 Years of Progress. http://www.hhs.gov/blog/2015/01/28/working-toward-tobacco-free-generation-51-years-progress.html
Schraufnagel, D.E., Blasi, F., Drummond, M.B., Lam, D.C., Latif, E., Rosen, M.J., et al. (2014).E cigs Electronic Cigarettes: A position statement of the Forum of International Respiratory Societies. American journal of respiratory and critical care medicine, 190(6), 611-618.
The Cancer Atlas (2014).Second Edition, American cancer Society. www.canceratlas.org
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Tobacco-free World (2015): summary, The Lancet.
Ugen, S. (2003). Bhutan: the world's most advanced tobacco control nation? Tobacco Control, 12(4), 431-433.
Ward, K.D. (2015).Tobacco Control, Waterpipe Tobacco Smoking: A Global Epidemic. 24(1).
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