Comprehensive guide to tobacco control policy implementation

The power of a treaty

INTRODUCTIONBeing the second most populous African country, Ethiopia represents a huge opportunity for the tobacco industry to recruit new smokers. Ethiopia signed the convention to ratify WHO Framework Convention on Tobacco Control (FCTC) in 2004 and ratified in 2014. We reviewed Ethiopia’s tobacco control legislative history pre- and post-ratification of the WHO FCTC and evaluated the level of compliance of the National Tobacco Control Directive (NTCD) with the WHO FCTC.METHODSWe reviewed Ethiopia’s tobacco legislative history, the NCTD, the National Tobacco Control Strategic Plan, and tobacco control related media stories from 2009 to 2018. The level of compliance of NTCD with WHO FCTC was compared and qualitatively analysed.RESULTSNTCD 2015 is Ethiopia’s first comprehensive tobacco control legislation, which for the most part is WHO FCTC compliant. The legislation prohibits, among other things, sale of flavoured tobacco products including menthol, sale of tobacco products to a person under the age of 18 years and bans all forms of tobacco advertising, promotion, and sponsorship. Yet, the current legislation allows smoking designated rooms in some prohibited places. Although a multi-sectoral National Tobacco Control Committee and a Strategic Plan were developed as per Article 5 of WHO FCTC, activities pertaining to the protection of such tobacco control policies from vested interests of the tobacco industry (WHO FCTC Article 5.3) are not addressed in NTCD 2015.CONCLUSIONSMajor gaps in the NTCD 2015 such as allowing smoking designated rooms should be addressed in order to stop the tobacco industry from using such loopholes to interfere with national tobacco control policies and/or maintain its tobacco market. Moreover, the tobacco control policies and efforts should be institutionalized across various sectors in order to ensure implementation of the NTCD.

igarettes are uniquely dangerous, killing half of all those who regularly use them and damaging the health of those who breathe in users’ smoke, particularly children. Just under a third of European adults currently smoke, and smoking has become increasingly associated with poverty, contributing significantly to widening health inequalities across the EU. In 2004, the ASPECT report, a comprehensive review of tobacco use and tobacco control policies in the EU, found that tobacco use caused well over half a million deaths in Europe annually and on top of that constituted a huge economic burden, estimated conservatively at E98-130 billion a year. 1 This review also identified that whilst some European countries were observing declines in tobacco use and mortality, in other countries tobacco use was still increasing, particularly among women. The ASPECT report identified 43 recommendations to combat the epidemic, covering tobacco control policy, interventions and research. Yet to date, few of these recommendations have been implemented, and as a result, future prospects for curbing the smoking epidemic across Europe are currently very bleak. On the optimistic side, in 2003, the world’s first public health treaty, the World Health Organisation’s Framework Convention on Tobacco Control (FCTC) came into force in recognition of the smoking pandemic and the power of the major transnational tobacco companies to push their deadly products. 2 The FCTC sets out supply and demand strategies to reduce tobacco use and has since been ratified by all EU countries (except the Czech Republic) and the European Union. The FCTC represents a unique and historic opportunity to fight the pandemic and collectively reduce the public health burden caused by tobacco and should therefore herald the way to faster progress in reducing smoking. However, the FCTC will only fulfil its potential if it is implemented in the most effective way and there is strong evidence that this is currently not the case. The Tobacco Control Scale (TCS) was developed by Joossens and Raw 3 to monitor the implementation of tobacco control

ObjectiveTo provide an overview of the effectiveness of global tobacco control policies using Interrupted Time Series (ITS) methodology and analyse key health outcome indicators and methodological differences in ITS studies.Data sourcesPubMed, Web of Science and Embase were searched for ITS studies on tobacco control policies from database inception to 1 July 2024.Study selection55 English-language studies were selected based on strict inclusion criteria.Data extractionThree researchers extracted data on study characteristics, design, conclusions and limitations.Data synthesisOf the studies, 28 used monthly time intervals, 40 focused on a single time break, 47 used non-Autoregressive Integrated Moving Average models, 40 considered seasonality, 34 controlled for confounding factors and only 13 included a control group. The implementation and evaluation of tobacco control policies demonstrated considerable geographical imbalance, with Europe reporting the largest number of evaluations (n = 23), followed by Asia (n = 12) and North America (n = 10), whereas South America (n = 4), multiple regions (n = 4) and Oceania (n = 2) were markedly under-represented. Overall, policies were associated with beneficial effects across multiple health outcomes, including reductions in emergency visit rate, hospitalisation rates, secondhand smoke exposure rate and smoking prevalence, although certain outcome measures exhibited notable heterogeneity.ConclusionsITS applications differ in time-interval selection, modelling and control of seasonality and confounding, contributing to result heterogeneity. Tobacco control policies are effective across multiple health indicators, though variability warrants further study. Future work should enhance reporting and methodological standardisation, particularly in control group use and statistical modelling, and strengthen policy implementation and evaluation in low- and middle-income countries to promote equitable global progress.

BackgroundSmoking is the largest preventable cause of death in the world, killing nearly 6 million people annually. This article is an investigation of measures implemented laws in the Iran to study the proposed strategy of control and reduce tobacco use based on the monitor, protect, offer, warn, enforce and raise (MPOWER) policy.MethodsAll laws approved by the Parliament along with the instructions on tobacco control prepared by the Ministry of Health and Medical Education, Ministry of Industry, Mine and Trade were collected and studied. Moreover, practical steps of Ministry of Health and other organizations were examined in this regard.FindingsIranian Parliament after the adoption of the Framework Convention on Tobacco Control (FCTC) acts to create a comprehensive and systematic program for tobacco control legislation as a first step towards comprehensive national tobacco control and combat. In this law and its implementing guidelines and based on the strategy of MPOWER, specific implement is done to monitor tobacco use and prevention policies, protect people from tobacco smoke, offer help to quit tobacco use, warn about the dangers of tobacco, enforce bans on tobacco advertising, promotion and sponsorship and raise taxes on tobacco. However, the full objectives of the legislation have not achieved yet.ConclusionAccording to Iran’s membership in the FCTC and executive producer of tobacco control laws and regulations, necessary infrastructure is ready for a serious fight with tobacco use. In Iran, in comparison with developed countries, there is a huge gap between ratified laws and performing of laws.

Significance. Over the past two decades, Russia has experienced a series of economic crises during which many individuals faced financial stress caused by debt, declining income, and fear of job loss. During the same period, the country has tightened its tobacco control policies, which were expected to reduce the prevalence of smoking. However, the effect of stress associated with crises on tobacco consumption remains unclear. At the same time, monitoring the population addictive behaviors during crisis periods is essential for developing public health protection tools and minimizing the adverse consequences of tobacco use for both smokers and society as a whole. Purpose. To assess the impact of economic crises, financial stress, and tobacco control policies on the prevalence of smoking among employed Russians. Material and methods. This study uses data from the Russian Longitudinal Monitoring Survey of the National Research University "Higher School of Economics", covering the period from 2000 to 2023. Statistical and econometric methods were employed, including binary choice models with fixed effects, to estimate the impact of different levels of financial stress and periods of economic crisis on smoking probability while controlling for individual-specific and temporal factors. Results. Cigarette consumption was found to be associated with financial stress, but this relationship varied depending on the level of stress, individual characteristics, and specific contextual factors such as the presence of crises and the stringency of tobacco control policies. Moderate and high levels of stress among men were associated with a reduction in smoking, whereas among women, a decrease in smoking was observed only under moderate stress. During the period of lenient tobacco control in 2008-2009, the number of cigarette consumers increased; the tightening of tobacco restrictions during the 2014-2015 crisis was accompanied by a significant decline in smoking prevalence; in 2020, despite the crisis, smoking prevalence remained stable under a moderate excise policy. Conclusion. The study confirms the need for an adaptive approach to tobacco control policy that considers the economic context and gender differences in the perception of financial stress. A reduction in smoking prevalence during economic crises is likely to be more effective when strict tobacco control measures are combined with social and psychological support for those who wish to quit smoking. It is recommended to develop gender-sensitive smoking cessation programs, expand educational and awareness campaigns, and integrate stress management and smoking cessation services. Scope of application. The results can be used to improve tobacco control policies during economic crises in order to decrease smoking prevalence among working men and women. Keywords: financial stress; economic crisis; anti-smoking policy; smoking prevalence; cigarette consumption.

BackgroundThe Framework Convention on Tobacco Control (FCTC), a World Health Organization treaty, has now been ratified by over 165 countries. However there are concerns that implementing the Articles of the treaty may prove difficult, particularly in the developing world. In this study we have used qualitative methods to explore the extent to which the FCTC has been implemented in Ghana, a developing country that was 39th to ratify the FCTC, and identify barriers to effective FCTC implementation in low income countries.MethodsSemi-structured interviews with 20 members of the national steering committee for tobacco control in Ghana, the official multi-disciplinary team with responsibility for tobacco control advocacy and policy formulation, were conducted. The Framework method for analysis and NVivo software were used to identify key issues relating to the awareness of the FCTC and the key challenges and achievements in Ghana to date.ResultsInterviewees had good knowledge of the content of the FCTC, and reported that although Ghana had no explicitly written policy on tobacco control, the Ministry of Health had issued several tobacco control directives before and since ratification. A national tobacco control bill has been drafted but has not been implemented. Challenges identified included the absence of a legal framework for implementing the FCTC, and a lack of adequate resources and prioritisation of tobacco control efforts, leading to slow implementation of the treaty.ConclusionWhilst Ghana has ratified the FCTC, there is an urgent need for action to pass a national tobacco control bill into law to enable it to implement the treaty, sustain tobacco control efforts and prevent Ghana's further involvement in the global tobacco epidemic.

The global burden of tobacco is a significant public health concern, causing millions of deaths, illnesses, and economic losses annually. In Türkiye, tobacco use is deeply ingrained in society, with historical roots dating back to Ottoman times. The nation faces challenges such as high smoking rates, gender disparities, and the popularity of non-cigarette tobacco products. Despite these issues, Türkiye has adhered to the WHO Framework Convention on Tobacco Control (FCTC) and implemented MPOWER strategies to combat tobacco use effectively. This review aims to synthesize Türkiye's comprehensive tobacco control measures, including legislation, smoking cessation initiatives, public awareness campaigns, and taxation policies. The study examines the country's strategic actions against the backdrop of its historical context and current challenges. The review leverages data from various sources, including the Global Burden of Disease, national health surveys, and reports on tobacco control efforts and achievements. Stakeholder activities, such as those by the Turkish Ministry of Health and non-governmental organizations, are also explored. Türkiye has made substantial progress in tobacco control, evidenced by reduced tobacco consumption and addressing key challenges like gender disparities and youth smoking. However, the country continues to face obstacles such as tobacco smuggling, the rise of narghile (hookah) smoking, and ongoing high daily smoking rates. The review highlights the tobacco industry's influence in Türkiye despite strong adherence to FCTC. Türkiye's efforts in tobacco control represent a significant endeavor to mitigate the public health crisis posed by tobacco use. Through adherence to WHO FCTC guidelines and MPOWER strategies, notable progress has been achieved. Yet, challenges persist, requiring continuous, comprehensive strategies and robust enforcement. Future efforts must focus on strengthening tobacco control measures, ensuring accessibility to smoking cessation services, and countering the tobacco industry's influence, to further reduce tobacco use and its health and economic burdens.

BackgroundTobacco use is a major risk factor for non-communicable diseases and policy formulation on tobacco is expected to engrain international guidelines. This paper describes the historical development of tobacco control policies in Nigeria, the use of multi-sectoral action in their formulation and extent to which they align with the World Health Organisation “best buy” interventions.MethodsWe adopted a descriptive case study methodology guided by the Walt and Gilson Policy Analysis Framework. Data collection comprised of document review (N = 18) identified through search of government websites and electronic databases with no date restriction and key informant interviews (N = 44) with stakeholders in public and private sectors. Data was integrated and analyzed using content analysis. Ethical approval was granted by the University of Ibadan and University College Hospital Ethics Review Committee.ResultsAlthough the agenda for development of a national tobacco control policy dates back to the 1950s, a comprehensive Framework Convention for Tobacco Control (FCTC) compliant policy was only developed in 2015, 10 years after Nigeria signed the FCTC. Lack of funding and conflict of interest (of protecting citizens from harmful effect of tobacco viz. a viz. the economic gains from the industry) are the major barriers that slowed the policy process. Current tobacco –related policies developed by the Federal Ministry of Health were formulated through strong multi-sectoral engagement and covering all the four WHO “best buy” interventions. Other policies had limited multi-sectoral engagement and “best buy” strategies. The tobacco industry was involved in the development of the Standards for Tobacco Control of 2014 contrary to the long-standing WHO guideline against engagement of the industry in policy formulation.ConclusionsNigeria has a comprehensive national policy for tobacco control which was formulated a decade after ratification of the FCTC due to constraints of funding and conflict of interest. Not all the tobacco control policies in Nigeria engrain the principles of multisectorality and best buy strategies in their formulation. There is an urgent need to address these neglected areas that may hamper tobacco control efforts in Nigeria.

Our objective was to describe the prevalence and changes in tobacco use and tobacco control policies in Latin American countries and cities before and after ratification of the 2003 Framework Convention on Tobacco Control (FCTC). Country-level tobacco policy data came from reports on the global tobacco epidemic (World Health Organization, 2007–2014). Global Youth Tobacco Survey data, 2000–2011, came from six countries (Argentina, Brazil, Chile, Colombia, Mexico, Peru), 31 cities and 132,065 students. Pre- and post-FCTC prevalence and relative changes were estimated. All countries showed improvements in tobacco control policies but Mexico and Peru showed the smallest improvements. In general, adolescents reduced their tobacco use, reported less exposure to smoking at home, more tobacco education, and more retailer refusals to sell them cigarettes. Adolescents reported smaller reductions in secondhand smoke exposure outside the home and no change in exposure to tobacco media/promotions. Pre-FCTC prevalence and relative changes during the post-FCTC period were more heterogeneous across cities than across countries. Despite overall improvements in tobacco policies and the decline in exposure to tobacco, policies related to media/promotions and secondhand smoke need strengthening. There was wide variation in adolescent exposure to tobacco between cities (within countries), which suggested major heterogeneity of policy implementation at the local level.

The Role of Public Policies in Reducing Smoking: The Minnesota SimSmoke Tobacco Policy Model

BackgroundThis study aimed to evaluate the association between tobacco control policies and trends in smoking cessation according to gender, age and educational level in Lithuania in 1994–2010.MethodsThe data were obtained from nine cross-sectional postal surveys conducted biennially within the framework of Finbalt Health Monitor project during 1994–2010. Each survey was based on a nationally representative random sample drawn from the National population register. The sample consisted of 3000 citizens aged 20–64 in 1994–2008 surveys and 4000 in the 2010 survey. In total, 17161 individuals participated in all surveys. The development of tobacco control policy in Lithuania was assessed using the Tobacco Control Scale (TCS). The association of the TCS scores with short-term and long-term quitting according to gender, age and education was examined using logistic regression analysis with control for secular trends.ResultsOver the last two decades, a large improvement in the development of tobacco control policy has been achieved in Lithuania. At the same time, this progress was associated with the increase in smoking cessation. A significant increase in both short-term and long-term quit ratios was found among people aged 20–44. An increase by 10 points on the TCS was associated with 17% increase in the odds of short-term quitting and with 15% increase in the odds of long-term quitting. The association between tobacco control policies and long-term quitting was stronger among younger than older people. No differential effect of tobacco control policies on smoking cessation was found in relation to gender and educational level.ConclusionsThe improvement in Lithuanian tobacco control policies was associated with an increase in smoking cessation in long-term perspective. These policies have not only benefitted highly educated groups, but lower educated groups as well. Nonetheless, further development of comprehensive tobacco control policies is needed in order to decrease social inequalities in smoking cessation.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-1525-8) contains supplementary material, which is available to authorized users.

Numerous studies document the causal relationship between prenatal smoking and adverse maternal and child health (MCH) outcomes. Studies also reveal the impact that tobacco control policies have on prenatal smoking. The purpose of this study is to estimate the effect of tobacco control policies on prenatal smoking prevalence and adverse MCH outcomes. The US SimSmoke simulation model was extended to consider adverse MCH outcomes. The model estimates prenatal smoking prevalence and, applying standard attribution methods, uses estimates of MCH prevalence and relative smoking risks to estimate smoking-attributable MCH outcomes over time. The model then estimates the effect of tobacco control policies on adverse birth outcomes averted. Different tobacco control policies have varying impacts on the number of smoking-attributable adverse MCH birth outcomes. Higher cigarette taxes and comprehensive marketing bans individually have the biggest impact with a 5% to 10% reduction across all outcomes for the period from 2015 to 2065. The policies with the lowest impact (2%-3% decrease) during this period are cessation treatment, health warnings, and complete smoke-free laws. Combinations of all policies with each tax level lead to 23% to 28% decreases across all outcomes. Our findings demonstrate the substantial impact of strong tobacco control policies for preventing adverse MCH outcomes, including long-term health implications for children exposed to low birth weight and preterm birth. These benefits are often overlooked in discussions of tobacco control.

Tobacco use is the most important preventable risk factor for premature death. The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), the first international public health treaty, came into force in 2005. This paper reviews the present status of tobacco control policies in Korea according to the WHO FCTC recommendations. In Korea, cigarette use is high among adult males (48.2% in 2010), and cigarette prices are the lowest among the Organization for Economic Cooperation and Development countries with no tax increases since 2004. Smoke-free policies have shown incremental progress since 1995, but smoking is still permitted in many indoor public places. More than 30% of non-smoking adults and adolescents are exposed to second-hand smoke. Public education on the harmful effects of tobacco is currently insufficient and the current policies have not been adequately evaluated. There is no comprehensive ban on tobacco advertising, promotion, or sponsorship in Korea. Cigarette packages have text health warnings on only 30% of the main packaging area, and misleading terms such as "mild" and "light" are permitted. There are nationwide smoking cessation clinics and a Quitline service, but cessation services are not covered by public insurance schemes and there are no national treatment guidelines. The sale of tobacco to minors is prohibited by law, but is poorly enforced. The socioeconomic inequality of smoking prevalence has widened, although the government considers inequality reduction to be a national goal. The tobacco control policies in Korea have faltered recently and priority should be given to the development of comprehensive tobacco control policies.

Nigeria plays important economic and political roles in Africa and is a significant market for the tobacco industry. This study describes the tobacco industry's efforts to block Nigeria's early tobacco control attempts, especially the Tobacco Smoking (Control) Decree 20 of 1990, and efforts to strengthen the Decree in 1995. Analysis of documents from the Truth Tobacco Documents Library and other Internet resources related to Nigeria's Decree 20 and earlier tobacco control efforts. The World Conferences on Smoking and Health and World Health Organization in the late 1970s spurred the Nigerian government to take steps towards tobacco regulation. In response, the tobacco industry lobbied government ministries, used front groups and its trade group, the Tobacco Advisory Council of Nigeria, to block and weaken government efforts. The industry obtained a draft of Decree 20 two years before it was enacted, considered the Decree anti-business and proposed language that led to the passage of a weaker Decree in 1990. It also attempted to influence a potential review of the Decree in 1995. Decree 20 was a strong law for its time, but was weakened due to tobacco industry interference. Nigeria ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2005, and enacted a comprehensive National Tobacco Control Act (NTCA) in May 2015. Lessons learned from Decree 20's experience should be applied to protect NTCA 2015, and in compliance with WHO FCTC Article 5.3 which require parties to protect tobacco control policies from tobacco industry interference. This is the first detailed account of tobacco industry interference with tobacco legislation in Africa. The emergence of tobacco control in Nigeria threatened the tobacco industry, which believed that success in Nigeria would have a "domino effect" in Africa. The industry used lobbying and front groups to successfully block and weaken Nigeria's tobacco control, especially the Tobacco Smoking (Control) Decree 20 of 1990 and efforts to strengthen it in 1995. Nigeria and other African countries must learn from this history to protect tobacco control policies from the tobacco industry's vested interests and vigorously implement Article 5.3 of the WHO FCTC.