May 31 is World No Tobacco Day, established in 1987 to increase awareness about the dangers of tobacco use. The World Health Organization estimates that tobacco use kills 8 million people annually. It’s a major contributor to health problems such as cancer, cardiovascular disease, respiratory diseases, stroke, diabetes, low birth weight and blindness.
World No Tobacco Day this year focuses on urging tobacco users to quit — 100 million users, in fact. Stressing health research that shows tobacco use is associated with higher rates of severe outcomes and mortality from covid-19, the WHO wants millions around the world to kick the tobacco habit. Here’s what you need to know about the global treaty on tobacco control and its effectiveness.
182 countries have joined the WHO’s tobacco control effort
Tobacco cessation programs are one aspect of the Framework Convention on Tobacco Control (FCTC), the first global public health treaty negotiated under the WHO’s auspices. Treaty negotiations began in 1996, after a decline in tobacco use in high-income countries by the mid-1990s created political space for action. The leadership of WHO Director General Gro Harlem Brundtland was crucial, as were regionally coordinated negotiating positions, media and civil society campaigns, and participation from other U.N. bodies.
In 2003, the World Health Assembly approved the FCTC, and it took effect in 2005. Today, 182 countries have joined in, although the United States is notably absent.
The treaty requires countries to pass evidence-based policies to curtail tobacco use. The acronym MPOWER sums these up: Monitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help in quitting tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising, promotion and sponsorship; and Raise taxes on tobacco.
Studies have shown the effectiveness of these policies for decreasing tobacco use. But experts also call for stronger policy implementation and enforcement, particularly in low- and middle-income countries, where 80 percent of tobacco users live. There is progress on some policies — advertising bans, for example — but stagnation on others, such as tobacco company sponsorship and smoke-free environments.
Implementing tobacco control efforts hasn’t been easy in Africa
Policy implementation has been highly uneven in sub-Saharan Africa, even though several African countries led the process for FCTC approval. In the past 35 years, tobacco use in the region has risen 50 percent, and tobacco-related deaths are also increasing.
My research illustrates some of the policy challenges in Africa. I conducted 22 interviews with African health advocates between 2014 and 2017, and analyzed news stories on tobacco from Ghana and Tanzania.
Many countries lack sufficient capacity to implement these policies. Health ministries often have only one or two staff members dedicated to tobacco control. Compliance with the FCTC guidelines requires government lawyers to write and interpret tobacco-control regulations — and police must then enforce sales restrictions. Health officials viewed strengthening civil society groups to be essential to get societal buy-in, so the public understands why compliance matters. Increasingly linked to trade and tax policies, tobacco control requires advocates to become versed in economics and finance.
Global advocacy on tobacco control has benefited from a consensus on policy solutions, as well as expanded reach into low- and middle-income countries. Global campaigns have stressed the detrimental health outcomes associated with tobacco use.
But the majority of Africans still die of communicable diseases such as tuberculosis, AIDS and pneumonia. One Ghanaian expert said, “When you go to the village, people are dying from malaria, HIV. … But hypertension [from smoking]? Those people are walking around.” Because health outcomes from tobacco use do not emerge for years, advocates must urge politicians to be proactive.
African health advocacy groups often lack resources, personnel and information to be effective. Tobacco control advocates’ financial reliance on donors such as Bloomberg Philanthropies and the Gates Foundation means that they may stress scientific arguments. But, as advocates pointed out, sometimes this evidence-based issue framing does not resonate with the population.
The dearth of data about tobacco’s health impacts in Africa makes some people question the urgency of prevention campaigns. And reliance on studies conducted in high-income countries that demonstrate tobacco’s harmful effects leads some people to view the issue as a “First World problem.”
Context matters, the research shows
My interviewees stressed the need to talk about tobacco control in ways that match local priorities. These priorities can sometimes get lost in global tobacco control advocacy circles, where activists from low-income countries are underrepresented.
African advocates stress not just lives lost, but also the cost to economic development. They point to tobacco taxes as a potential revenue source, and for tobacco-producing countries, they highlight the long-term environmental cost of tobacco farming. Increasingly, human rights advocates point to the poverty of tobacco growers, the dangers of secondhand smoke to children’s health and the use of child labor in tobacco farming.
Context matters in others ways. Tobacco use rates vary widely across African countries — but there’s an association between poverty and tobacco use. In Ghana, smoking rates are highest among men with low income and low education, a pattern found in other African countries. The socioeconomic and political marginalization of these populations may make it easier for officials to play down the need for tobacco control to improve health.
Stigma against tobacco use deepens this marginalization. African young women, whose tobacco use rates have increased, may be judged negatively if they smoke. Although people with strong religiosity are less likely to use tobacco, my informants reported that deeply religious smokers were also more likely to hide their habit, even from health-care providers.
Stigma may discourage smokers from seeking help, and lead policymakers to distance themselves from the tobacco issue. In their campaigns, local advocates often struggled to address these dynamics in tobacco use across demographic groups.
Pandemic stress may have boosted tobacco use, ironically
The coronavirus pandemic may challenge tobacco control efforts. Although data are limited, stress and isolation may be contributing to increased cigarette use in the United States. And tobacco cessation advocates could face more competition for resources and policymakers’ attention. But the pandemic has shown how infectious-disease outbreaks interact with noncommunicable diseases to increase illness and death. Preventing these outcomes through implementation of tobacco control policies matters as countries seek to recover from the pandemic, and address future global health challenges.
Amy S. Patterson (@aspatter_amy) is professor of politics at University of the South, and author of Africa and Global Health Governance: Domestic Politics and International Structures (Johns Hopkins University Press, 2018). She studies community mobilization, citizenship and health policy priorities, with a focus on Africa.