Global advocacy for controlling the tobacco industry

Readers of the Medical Journal of Australia might be forgiven for assuming that the global impact of the tobacco industry has been greatly reduced. Australia is a world leader in tobacco control, based on its longstanding commitment to effective policies, and prevalence rates are declining rapidly. Globally, however, 30% of men and 6% of women still smoke. Further, projections suggest the internationally agreed target of a 30% reduction in smoking rates (base year: 2010) by 2025, established as part of the World Health Organization's global non-communicable disease action plan, will not be achieved.1

Tobacco is a uniquely harmful product; two out of three smokers' deaths result from their tobacco use, with a loss of an average 10 years of life.2 In the decade since the landmark WHO Framework Convention on Tobacco Control (FCTC)3 was adopted, around 50 million people, mostly men living in poorer countries, have died from using tobacco, and Big Tobacco continues to be very profitable.

The FCTC is a major advance in global tobacco control, although most countries have yet to meet their obligations under the convention. Most need to speed up the implementation of key components of the treaty: increased taxation, complete bans on tobacco advertising, promotion and sponsorship, and guarantees of smoke-free environments. Countries that have yet to ratify the FCTC, especially those where the tobacco industry is entrenched, ranging from Indonesia to the United States, should do so urgently. The FCTC alone, however, will not be enough to achieve a tobacco-free world, and will not stop the tobacco industry actively recruiting new smokers, especially women, a largely untapped growth market.

Time for action

It is time to acknowledge and act on the unacceptability of the damage done by the tobacco industry. How might we reverse the tobacco industry-driven pandemic? The Lancet recently published a series of three articles that discussed this question.4-6 In the first, we proposed the goal of a tobacco-free world by 2040; the sale of tobacco would be phased out over the next quarter of a century, although not prohibited.4 In this ambitious vision, less than 5% of adults would be using any form of tobacco in 2040.

The cause of the tobacco pandemic is the tobacco industry — lethal but still lawful — and its predatory efforts to maintain profits by exploiting markets in middle- and low-income countries.5 With its vast resources, the industry undermines and distorts tobacco policy in many countries. Some of its cynical efforts, however, have been countered in several high-income countries; for example, by plain packaging legislation in Australia,7 with similar legislation in Ireland and the United Kingdom following in March this year.8

Achieving a tobacco-free world by 2040 will require concerted and coordinated action at global, regional and national levels, especially in large countries such as China, where one in three of the world's smokers lives. Although there is progress, the very close relationship between the tobacco industry and the Chinese government needs to be broken.6

Several countries have set their sights on essentially tobacco-free societies by 2025 (New Zealand9 and Pacific countries10) or later (Finland11 and Scotland12). These countries should be seen as models for regional and global efforts to achieve a tobacco-free world. Australia, for one, should also set a goal for reducing the prevalence of tobacco use to less than 5% by 2025. A strong development case can also be made for greater leadership from the United Nations in support of the WHO and its goal of a tobacco-free world by 2040. As tobacco is an impediment to human development, it would be appropriate for the post-2015 Sustainable Development Goals currently being discussed by the UN to include a strong tobacco control target, building on the work of the FCTC. The FCTC itself could be usefully amended to include a target date for phasing out the sale of commercial tobacco products.

Progress is possible — but needs investment

There are no serious downsides to adopting an ambitious goal for reducing tobacco use, as long as it does not deflect attention from the accelerated implementation of the FCTC. Indeed, focusing on tobacco has a multitude of benefits: it will support calls for improving health systems, make universal health coverage more attainable, and reduce the damage done to people throughout their lives. Ambitious goals have been instrumental in rapid improvements in other areas of public health, such as reducing the mortality of childhood diseases and HIV/AIDS. These positive trends, however, have required the investment of resources. Development agencies should extend the scope of their activities to supporting national tobacco control efforts, building on the contributions of Bloomberg Philanthropies and the Bill and Melinda Gates Foundation. Finally, the ability of countries to promote health, including through tobacco control policies, must be protected from the so-called “free” trade agreements currently under discussion.

The goal of a tobacco-free world is socially acceptable, technically feasible and could easily become politically practical. Current global anti-tobacco strategies are clearly insufficient. National and international leadership is urgently needed to counter the burdens on health and human development caused by the tobacco industry. In Australia, the priority is continuing increases in the taxation of tobacco products beyond the current 4-year cycle, increased investment in mass media campaigns, and actions targeted at vulnerable groups, including Aboriginal Australians and people with mental health issues. All Australians, including readers of this Journal, should further pursue their important advocacy role at home and abroad.