While all six of the World Health Organization’s cost-effective, high-impact MPOWER measures are critical to ending the global tobacco burden, the “O” in this acronym—“Offer help to quit tobacco”—has, to date, been under implemented. When the WHO issued its last Report on The Global Tobacco Epidemic in 2019, it found that just 23 countries—home to some 2.4 billion people—were delivering cessation support policies at the highest level; this was certainly an improvement from 2007, when only 10 countries were providing comprehensive cessation programmes, but there is still significant work to be done. Today, according to WHO, some 780 million people say they want to quit tobacco, but only 30% of them have access to the tools needed to overcome the mental and physical addictions that keep them hooked.
This must change. Parties to the Framework Convention on Tobacco Control (FCTC) are obligated, under Article 14, to promote tobacco cessation and treatment for tobacco dependence. Countries must integrate tobacco interventions into primary care; create and provide counselling services; offer free quit helplines; and facilitate access to and affordability of smoking cessation medications and nicotine replacement therapies (NRTs), which can cut cravings and ease the physical discomforts of nicotine withdrawal.
“Smoking is a key determinant of health inequalities between and within countries. Free, targeted and tailored tobacco cessation support for all smokers is an urgent need in low- and middle-income countries (LMICs) and economically disadvantaged groups in high-income countries”, said Dr Omara Dogar, Chair of The Union’s Member Tobacco Control Section. There is no national cessation strategy in many LMICs and unaided cessation rates are very low – at about 5% over a year, despite smokers being motivated to quit.
It is estimated that about 45% of male doctors in these countries smoke. Dr Dogar added: “Helping healthcare workers stop smoking, mandating recording of tobacco use in medical notes and integrating brief advice to quit in primary care, would enable LMIC health systems to achieve smoke-free facilities supporting a huge number of patients that come in contact with them”.
Smoking rates among adults with mental health conditions are also quite high compared to the general population. For example, it is almost double the national average in the UK. The gap in smoking rates between social classes is also considerable and increasing in countries where smoking has declined in the past few decades. These sub-groups of populations need focused approaches to tackle the issue.
Tobacco and nicotine product producers frequently propose that heated tobacco products (HTPs) and e-cigarettes are critical to global tobacco control and market these products as important tools for “harm reduction.” HTPs are tobacco products and should not be proposed as “safer” alternatives to combustibles; the majority of studies suggesting that they are less harmful and/or effective cessation aids are funded by the tobacco industry. If used exclusively—and in lieu of traditional cigarettes—e-cigarettes may decrease smoking harms for individuals who have not been successful with other efforts, but the dominant pattern is dual use, which has been increasingly found to be associated with short-term and long-term health effects. “Switching from conventional tobacco products to e-cigarettes is not quitting,” cautions the WHO, which notes that there is inconclusive scientific evidence on the cessation efficacy of these products and that the tobacco industry’s interests are “irreconcilably opposed to promoting public health.”
“To truly help tobacco users quit and to strengthen global tobacco control, governments need to scale up policies and interventions that we know work,” wrote WHO Director-General Tedros Adhanom Ghebreyesus in The Lancet. “Tried and tested interventions, such as nicotine and non-nicotine pharmacotherapies, should be promoted for cessation.”
The Union shares the WHO’s position, and in our 2020 position paper, “Where Bans are Best,” we called for LMICs—where markets are not yet saturated with HTPs and ENDS—to act, before novel products wreak irreparable damage. We noted that e-cigarettes, HTPs, and hybrid products will likely exacerbate the tobacco epidemic by hooking a new generation of users, particularly young people, who are lured by advertisements, event sponsorships, and flavors. In addition to the aforementioned argument about limited cessation efficacy and insufficient harm reduction evidence, our paper reiterates that context matters. Tobacco control enforcement—on smokefree, advertising bans, and vendor licensing—is currently weak in many LMICs. There is great potential to exploit loopholes, which can facilitate twin epidemics of addiction to novel products and traditional cigarettes. Again, while acknowledging that there may be isolated cases of smokers using e-cigarettes to transition from combustibles, the net public health outcome of novel products—which weighs the impact on both smokers and non-smokers (particularly youth)—must be the final verdict. It is likely to be negative in LMICs.
Today, on World No Tobacco Day, we want to reiterate that it is critically important to do two things simultaneously: scale proven cessation services and treatments and ensure that novel products are not erroneously promoted for quitting. We also want to call attention to several important developments.
First, we are pleased to support WHO’s year-long global “Commit to Quit” campaign. Launched on 8 December 2020, the campaign focuses on 22 priority countries—these include Brazil, Pakistan, Bangladesh, China, India, Indonesia, Philippines, Vietnam, Mexico, and Ukraine—and includes a suite of services that connect tobacco users to supportive digital communities that can facilitate quit efforts. The campaign aims to help 100 million users stop using tobacco and includes the powerful publication, “More than 100 reasons to quit tobacco.”
Second, The Union is working with high burden, low- and middle-income countries where e-cigarettes and HTPs are being aggressively introduced, often with little or no regulatory framework in place. These products are being heavily marketed to new users, including youth. For these reasons we support and recommend that countries develop and adopt evidence-based, precautionary approaches to novel product regulation.
Over the past year, there have been important policy developments:
- After being given authority over e-cigarettes and other new tobacco product regulations in 2019, the Philippines’ Department of Health issued a December 2020 Administrative Order, (AO) 2020-0055—“Regulation on Vapor Products and Heated Tobacco Products under the Food and Drug Administration” last December 2020. In addition to establishing a Novel Tobacco Regulatory Unit under the Food and Drug Administration (FDA) and stipulating that e-cigarette and HTP packaging must have graphic health warnings, the Order gives the FDA significant authority over these products. For example, neither e-cigarettes nor HTPs can be manufactured, imported, exported, or sold without an FDA license, and the FDA is mandated to continuously monitor health issues arising from product use.
- In April 2021, Mexico’s Lower Chamber approved an amendment for the Tobacco Control Act that would broaden the definition of “smoke-free” to include Electronic Nicotine Delivery System (ENDS) and HTP emissions. If it passes the Senate in the critical next step, the amendment will prohibit the use of ENDS and HTPs in public places, including restaurants, public transportation, educational facilities, including universities.
“COVID-19 has devastated communities and is presently decimating much of South Asia, but there may be a silver lining to this pandemic as more people embrace the importance of lung health and the urgency to cease using tobacco,” said Gan Quan, Director of The Union’s Tobacco Control Department. “The WHO’s ‘Commit to Quit’ campaign provides evidence-based, digital tools to help users stop using a lethal product, and, in the past year, low- and middle-income countries have taken important steps to limit novel product availability. Combined, the campaign and policy changes can be the one-two punch to turn the tobacco epidemic around.”