Tobacco control is working--slowly. The number of people smoking worldwide has declined and tobacco-attributable deaths are falling.
This progress is evident in WHO's fourth report on international tobacco trends, released on Nov 16, which estimates 1·30 billion tobacco users globally in 2020, compared with 1·32 billion in 2015. 60 countries are now on track--versus 32 countries 2 years ago--to achieve the voluntary global target of a 30% reduction in tobacco use between 2010 and 2025. Such progress is welcome. But as tobacco elimination nears, progress will become more difficult and incremental gains will be harder won. Accelerated advocacy and action are required.
Only a fraction of countries has adopted the comprehensive package of policies under the WHO Framework Convention on Tobacco Control (FCTC) and the MPOWER measures, which include taxation, smoke-free laws, advertising and sponsorship bans, and tobacco dependence treatment. Implementing these policies should remain the priority, especially in WHO's South-East Asia region, where 29% of the population use tobacco. In China, India, and Indonesia--home to nearly half of all global tobacco users--there must be markedly increased investment and strengthened policy to end smoking and its health impacts.
In their pursuit of tobacco control, governments and practitioners worldwide can draw lessons from the UK example. This month Action on Smoking and Health (ASH), the prominent UK anti-smoking organisation, marks its 50th anniversary. When the charity was established by the Royal College of Physicians in 1971, two-thirds of men and four in ten women in the UK smoked. In 2021, just one in six people were cigarette smokers. The UK has achieved this reduction by introducing tobacco taxation above inflation every year, implementing comprehensive smoke-free laws, requiring tobacco products to be out of sight in shops, mandating large health warnings and plain standardised packaging, and implementing an anti-smuggling scheme that tracks all cigarette products. Smoking prevalence in the UK has declined faster than other global leaders in tobacco control, such as Australia, and far faster than the average for Europe.
None of these achievements would have been possible without advocacy by organisations such as ASH, whose approach provides a playbook for others. First, communicate the evidence. ASH was successful in building on epidemiological studies in the early 1960s linking smoking and lung cancer, constantly engaging the media to help report evidence of the harms of smoking. This tactic remains vital for all advocates in 2021, as the rise of social media and rapid circulation of misinformation threaten trust in public health advice.
Second, build alliances. Since the beginning of its work lobbying government in the 1970s and 1980s, ASH used its partnership with the Royal College of Physicians to forge broader alliances with health professionals and associations. The support and credibility provided by these partnerships have helped spur action over decades and were in clear evidence again last week when 600 health leaders joined forces to pressure the UK Government to produce its overdue tobacco control plan and introduce important changes to a health bill being debated in parliament.
Third, actively oppose industry. The tobacco industry has always exploited any opportunity to evade regulation. Evidence shows, for example, that the tobacco industry used the COVID-19 pandemic to build influence with governments in 80 countries. ASH continually works against the influence and viability of industry, including its current advocacy for levies on tobacco manufacturers. Its so-called polluter pays levy proposal penalises companies rather than the consumer, generating revenues to fund needed public health action.
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Tobacco control is far from over. In the UK, there are still 7 million smokers. With current declines of 0·5 percentage points per year, the government's ambition for England to be smoke-free and for smoking to be obsolete by 2030 is nowhere near on track, says ASH. Worse, smoking rates among young adults between 18 and 34 years have increased by 25% during the pandemic.
Globally, over 20% of people still smoke tobacco. In no country in the world is tobacco yet obsolete. Tobacco remains a leading cause of premature death and kills 8 million people a year. Although overall trends provide reassuring incremental progress, regional gains are uneven and worrying. Countries behind in their compliance with FCTC agreements must push for implementation of proven anti-smoking policies. Health professionals worldwide must continue to participate in advocacy, driving tobacco control to the finish line.
