Experts call for a tobacco-free world by 2040

Writing in a major new Series in The Lancet, an international group of health and policy experts, led by Professors Robert Beaglehole and Ruth Bonita from the University of Auckland in New Zealand, call on the United Nations (UN) to lead a "turbo-charged" effort against the sale and consumption of tobacco.

The Series will be launched in Abu Dhabi, United Arab Emirates, at the 2015 World Conference on Tobacco or Health, the world's largest gathering of tobacco control advocates, policy makers, researchers, public health and clinical experts.

One billion deaths from smoking and other forms of tobacco use are expected by the end of this century if efforts to tackle tobacco use are not accelerated. More than 80% of these deaths will be in low- and middle-income countries, whose populations will be most severely affected by the devastating economic and social burden of tobacco illness caused by tobacco in coming decades.

According to Professor Beaglehole, "The time has come for the world to acknowledge the unacceptability of the damage being done by the tobacco industry and work towards a world essentially free from the legal and illegal sale of tobacco products. A world where tobacco is out of sight, out of mind, and out of fashion -- yet not prohibited -- is achievable in less than three decades from now, but only with full commitment from governments, international agencies, such as UN and WHO, and civil society."

A decade on from WHO's landmark introduction of the Framework Convention on Tobacco Control (FCTC), only 15% of the world's population have adequate access to smoking cessation programmes. Moreover, less than one in ten people worldwide are covered by tobacco taxation at levels recommended by the FCTC, despite research showing that increasing the cost of tobacco to the consumer through taxation is one of the most effective ways to reduce consumption. In the same period, 50 million deaths have been caused by tobacco, indicating that the FCTC alone is insufficient to achieve substantive reductions in the use of tobacco.

In a new research Article, published in The Lancet to accompany the Series, Professor Kenji Shibuya from the University of Tokyo, Japan, and colleagues show that although overall rates of smoking are slowly declining, the prevalence of tobacco usage is actually expected to increase in some countries over the next decade, notably in Africa and the Middle East. And because the world's population is rising, there will still be more than one billion smokers in 2025, unless global action against tobacco accelerates markedly.

Although implementation of the FCTC has been successful in some countries (particularly in those such as Australia, New Zealand, Finland, United Kingdom, Ireland, Scotland and some Pacific Island countries, which have led the way in implementing strong tobacco reduction policies), global tobacco regulation now needs to be "turbo-charged," say the Series' authors. This can be achieved by accelerating the FCTC in individual countries where implementation has been slow or incomplete, including tobacco reduction goals in the Sustainable Development Goals -- which are expected to strongly influence UN member states' agendas and political policies over the next 15 years -, and for the UN to take a leading role in galvanising global and national action to eliminate the sale and use of tobacco.

While FCTC regulations have done much to reduce tobacco usage, the Series' authors argue that until now, regulatory efforts have been too focused on reducing demand for tobacco, and further progress will be threatened unless the supply of tobacco -- dominated by just four major international companies, and the state-owned Chinese National Tobacco Company -- can be tackled through stronger regulations and closer scrutiny of the industry's conduct.

Falling rates of tobacco usage in high-income countries have increased the need for the "big four" tobacco companies to turn their attention to low- and middle-income countries, especially in Africa and Asia [see Paper 3]. Tactics include industrial litigation, lobbying through third-party groups (whose links to industry aren't always clear), and covert maintenance of political pressure disguised as "corporate social responsibility," including sponsorship of social projects, and events aimed at women or young people.

"Contrary to industry claims, tobacco marketing deliberately targets women and young people," says Professor Anna Gilmore, from the University of Bath, UK. "The tobacco industry continues to interfere with governments' efforts to implement effective tobacco control policies. If the world is to become tobacco free, it's vital that the industry's appalling conduct receives far closer scrutiny and countries which stand up to the industry's bullying tactics receive better global support ."

While the "big four" tobacco companies dominate the industry in much of the world, in China, tobacco production is controlled by the state-owned Chinese National Tobacco Company [see Paper 2]. Here, implementation of effective tobacco regulations has been hindered by the fact that tobacco production, sales, and regulation are all effectively controlled by the same, state-owned, body. With China thought to have 300 million smokers -- more than any other country on Earth -- the government now needs to build on the progress it has made in some areas of tobacco control, and separate out tobacco regulation from a powerful industry whose interests rely on smoking continuing.

According to Professor Gonghuan Yang, from the Peking Union Medical College in Beijing, China, "The prevalence of tobacco use among adult men in China is one of the highest in the world and is increasing; 1·4 million deaths in China were attributed to tobacco use in 2010."

While some promising developments in nationwide legislation are under consideration -- including protecting people from second-hand smoke and banning all forms of tobacco advertising, promotion, and sponsorship -- the next challenge will be to increase cigarette tax and changes to health warnings on standardised cigarette packaging to reduce tobacco consumption. Professor Yang states "China has the potential to be successful in tackling the pandemic of tobacco use among Chinese people, but only if the governmental structure is changed to allow tobacco regulations to be implemented independently from the tobacco industry."

A research Article published in The Lancet Global Health alongside the Series uses extended cost-effectiveness analysis (ECEA) to show that in China a substantial (e.g. 50%) increase in tobacco price through excise tax can be a pro-poor policy instrument that brings substantial health and financial benefits to households in China, especially concentrated among the poorest socio-economic groups.