© Oxford University Press 2006.
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World Health Organization Focuses On Antitobacco Efforts in Developing Nations Through Treaty
In a pledge to reduce 8 million cancer deaths worldwide by 2015, the World Health Organization is intensifying its antitobacco efforts by focusing on developing nations.
Unlike much of the developed world where tobacco use is declining, smoking is on the upswing in many low- and middle-income countries, and worldwide cigarette consumption is actually rising. Without serious efforts to prevent youth from starting and help current smokers quit, rates of tobacco-related deaths will skyrocket this century, said Peter Boyle, Ph.D., director of the International Agency for Research on Cancer in Lyon, France, WHO's research arm. To meet this challenge, the WHO has pledged to strengthen its global tobacco surveillance, intensify its prevention efforts, and better coordinate its work with other agencies.
Most of the enforcement will come through the Framework Convention on Tobacco Control (FCTC), the first-ever legally binding international health treaty and WHO's primary weapon against tobacco. In February, member nations met for the first time since it was ratified in May 2005 to discuss progress in implementing antitobacco measures in the 124 WHO member states who have signed on (70 eligible nations have not, including the United States) The treaty says that member nations must increase the price of and taxes on tobacco, institute and enforce bans on tobacco smoking and advertising, and restrict sales to minors. These are all measures that have proven effective in reducing tobacco consumption, said Marta Seoane, communications officer for the Tobacco-Free Initiative.
WHO's antitobacco push is part of a larger effort to reduce cancer worldwide. Tobacco use is the most preventable cause of death and the most serious risk factor for cancer. Currently, 1.3 billion people smoke or use tobacco and nearly 5 million die from it each year, with half of those deaths occurring in prime working years, between ages 35 and 69.
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"Until relatively recently, infectious diseases were the developing world's most pressing public health challenge, but their disease burden is shifting to chronic diseases: cancer, chronic obstructive pulmonary disease, heart disease, and obesity, all traditionally considered to be diseases of high-income nations," said Andreas Ullrich, M.D., who heads WHO's cancer control program.
Most of the world's tobacco users, 84%, live in countries with a developing or transitional economy. By 2020, WHO estimates that the global burden of smoking-related deaths will surpass 9 million annually—with 7 million in developing nations. That's a big change from 25 years ago, when almost 70% of the world's lung cancer deaths occurred in high-income nations; now 50% of lung cancer deaths occur in low-income nations. By 2030, the figure will rise to 70%.
"Even if smoking rates stayed the same worldwide, we would see a huge increase in cancer incidence in the next decades just because of the growth and aging of the population," Boyle said. "Whereas there were 100 million deaths in the 20th century caused by tobacco, if current trends continue, there will be 1 billion in the 21st century. Tobacco is the biggest enemy we face."
In light of these numbers, the FCTC is especially important because lower-income nations have generally lagged behind in tobacco control measures. Tobacco use is highest among the poor and illiterate in many countries, and it creates a vicious cycle of poor health and ongoing poverty. Smokers in developing nations spend a higher percentage of their income on cigarettes and less on food, education, and health care. And tobacco's impact on productivity and longevity is more profound in low-income countries. A recent study showed a 20-year gap in life expectancy between smokers and nonsmokers in Bangladesh, whereas in the Western world there is a 10-year difference.
"In the developing world, the nonsmoking message has not reached everyone," said Joy de Beyer, former Tobacco Control Coordinator at the World Bank and currently in the global HIV/AIDS program. "And in many developing nations, tobacco companies have stepped up marketing efforts to compensate for decreasing smoking rates in many developed nations."
Smoking is not the only problem; tobacco use extends to chewing tobacco and other traditional methods. Chewing tobacco is common throughout the world but is especially popular in Southeast Asia. In Mumbai, India, for example, 56% of women chew tobacco, although few smoke cigarettes. Bidis—tobacco hand wrapped in a temburni leaf and tied with string—are India's most popular form of tobacco, and the small package can deliver more tar and carbon monoxide than a manufactured cigarette. The WHO will focus on this problem on World No-Tobacco Day, May 31, with the theme "Tobacco is deadly in any form or disguise."
Some of the FCTC's treaty provisions deal with this problem directly. Raising tobacco prices is the most powerful and cost-effective policy tool to reduce tobacco use, according to the World Bank. The key target groups, youth and low-income individuals, respond most strongly to higher tobacco costs. When tobacco prices dropped, products in India, Nepal, Indonesia, Sri Lanka, and Thailand became about 50% more affordable during the past 20 years and use rose. In New Zealand, where prices more than tripled, use dropped. South Africa, Brazil, and Poland have reduced smoking rates by raising tobacco prices and limiting advertising, and the treaty's measures should help accelerate similar changes elsewhere, de Beyer said. She pointed to China and India, home to many millions of smokers, as places where higher prices and other antismoking policies could do much to reduce smoking and improve health.
The FCTC treaty is the culmination of a 4-year process to create both a legal framework and roadmap to help nations cut tobacco use. "The FCTC is not imposing policies from without; its provisions were hammered out and agreed upon by all participating nations," de Beyer noted. They include deadlines, like 3 years to enforce health warnings on tobacco products and 5 years to implement comprehensive bans on tobacco advertising, promotion, and sponsorship. The FCTC is a minimum standard and it encourages nations to go beyond the treaty. The signatories represent 69% of the world's tobacco consumption.
"The good news from the treaty's first meeting in February is that some new nations with high rates of smoking, like Albania, are now in discussions with [WHO] regional offices for the first time to discuss how to implement plans to reduce tobacco consumption," Ullrich said.
About the same percentage of nations from the developed and developing world have signed onto the FCTC and reported progress since it came into force 9 months ago. Successes include India's introduction of comprehensive tobacco advertising bans; banning smoking in public places in Spain, Ireland, Norway, and Uruguay; and introducing highly visible graphic warnings on cigarette packs in Australia, Brazil, Canada, Thailand, Singapore, and Uruguay.
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The February meeting also discussed issues not yet included in the treaty's provisions, like smuggling, cross-border advertising, financial support for developing nations programs, ways to collect information on whether countries are complying, and what has or hasn't worked. A major focus was on the economics of tobacco control in the developing world, which they will study further. Several FCTC members want to help tobacco farmers switch to alternative crops, but they need to decide what alternatives will be profitable and how to fund the change in countries heavily dependent on tobacco.
The fight against tobacco is the same almost everywhere, but the developing world has less money to deal with it and more problems competing for those scarce resources, Seoane said. Tobacco still competes with diseases like HIV/AIDS and malaria for a top spot for resources. WHO's goal in developing nations is to push tobacco to the top of all nations' health agenda.
"The FCTC treaty will be instrumental in making sure that developing nations also implement and benefit from cost-effective, proven policies to reduce tobacco use, which will prevent unnecessary death and disease in millions of people," de Beyer said.
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