Margaret Harris Cheng, The Lancet
Member states of WHO’s Western Pacific region have unanimously agreed on a new action plan to tackle the huge burden of tobacco-related illness in the region. Margaret Harris Cheng reports.
To the surprise and delight of tobacco-control campaigners, a plan to operationalise the Framework Convention on Tobacco Control (FCTC) was passed with barely a murmur of dissent at the WHO’s Western Pacific regional meeting held in Hong Kong last month.
Although representatives of three of the world’s biggest tobacco producers—China, the USA, and Japan—were present when the plan came up for discussion, only China voiced any misgivings about the plan. “The action plan should offer guidance—it should not be a mandatory requirement for member states”, China’s representative told the meeting.
The ease with which the plan was accepted was a surprise because it is considered a radical departure from its predecessors (this is the fifth such plan for the WHO’s Western Pacific region). For the first time, the plan sets out objectives for member states and a timeframe (2010—14) in which those objectives should ideally be reached. All member states are expected to attend a progress review in 2012, and be ready and willing to explain what stage they are at with tobacco control and why they have, or have not, achieved their objectives.
It was this, the setting of very specific objectives, that made China somewhat uncomfortable. But the USA (which attends such meetings on behalf of its Pacific territories and protectorates) and Japan fully endorsed the plan. “Japan has been strengthening tobacco control based on the national health promotion policy…but the male rate is still higher in Japan compared to other countries”, said Japan’s representative.
The Americans simply stated support for tobacco control without commenting on specific problems in their Pacific territories. Their representative Mark Abdoo said, “the US is committed to tracking morbidity and mortality associated with tobacco use. We also remain dedicated to preventing death and disease from tobacco use. The tobacco surveillance system is evidence of our commitment”.
Although the ease with which the plan was accepted surprised observers, all agreed that the region has been ahead of the rest of the world in terms of accepting the need for controlling tobacco use. The Western Pacific region was the first, and so far, only WHO region to get all member states to ratify the FCTC—something achieved in 2006.
“WPRO [the Western Pacific region] has been ahead of the race for a very long time but this [plan] is a step further because it has all sorts of measurables, deliverables. We’ve really pushed the envelope out—it’s very, very specific. And by 2014 those things will be evaluated”, said Judith Longstaff Mackay, senior adviser to the World Lung Foundation and a member of the Hong Kong delegation to the meeting. “Recognising that this [the FCTC] is on wheels now, this is what all the neighbours are doing. It’s united us all, really stiffened the backbone of many countries”, said Mackay.
What the plan does not do, though, is offer any sanctions for states that pay little more than lip service to tobacco control.
While agreeing that the plan was “more carrot than stick”, Susan Mercado, Western Pacific regional adviser for the WHO’s Tobacco Free Initiative, pointed out that the significance of the plan was that it was the first to introduce ways to measure real progress in tobacco control. “This is the first time the region has come up with regional targets and indicators…we are moving forward in terms of accountability, measuring progress, and identifying gaps in capability…Some people won’t be comfortable with it, but if people are comfortable with tobacco control, it’s not working.”
The plan is ambitious, setting targets like achievement of clear guidance on how to avoid conflicts of interest with the tobacco industry in 100% of countries. These targets are likely to be difficult to meet for a member state like China where the trade and agriculture ministries are responsible for tobacco growth and production and there is strong political pressure to maintain the status quo to avoid loss of livelihoods and social chaos.
However, Douglas Bettcher, director of the Tobacco Free Initiative, said Thailand, which also has a state tobacco monopoly, had achieved this very thing by “creating a firewall between the policy makers for tobacco control and the state tobacco monopoly…it really represents the gold standard, how best to operate. Thailand’s a government we’d like to see other governments following.”
Getty Images Some nations in WHO's Western Pacific region have already banned indoor smoking (Lancet)
Getty Images China has the world's largest state-owned tobacco industry and number of smokers (Lancet)
A package of policies developed by the WHO in 2008 and given the acronym MPOWER (Monitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help to stop tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising; Raise taxes on tobacco) is underpinning the new action plan.
Member states are expected to develop legislation and policy for protection from second-hand smoke that “are compliant with the definition of 100% indoor smoke-free settings (eg, workplaces, public transport, indoor public places)”, regulate tobacco product labelling in compliance with the FCTC (using pictorial warnings), and put comprehensive bans on tobacco advertising in place.
By 2014, all countries in the WPRO region are expected to “have developed action plans, or equivalents, and established or strengthened national coordinating mechanisms, as appropriate”, ratified all FCTC protocols, and gathered reliable data about tobacco use in adults and young people.
Some Western Pacific nations are already leading the way in terms of data gathering. Member states with advanced economies and health systems like Hong Kong and Singapore have been tracking their smoking prevalence rates for decades and both can now point to substantial reductions in prevalence.
Hong Kong, which has implemented most of the policies outlined in the MPOWER package already, can point to an impressive drop in prevalence since the early 1990s. In 1992, Hong Kong had a 23% prevalence of tobacco use but by 2005 this had dropped to 14% and has fallen further to 12% in 2008. During that time, Hong Kong progressively banned tobacco advertising, sports sponsorship by cigarette companies (in the late 1990s), smoking in the workplace, then in public spaces like shopping malls and parks and, most recently, in clubs and bars. Some bars and parts of clubs still have permits for smoking areas but indoor tobacco smoke has all but disappeared in Hong Kong. “This shows that tobacco control is not the prerogative of western countries and that Asian countries can implement effective tobacco control… We now know what works”, said Mackay.
Although Hong Kong has been part of China since 1997 when it was handed over by Britain, the territory has very different tobacco laws and practices from the rest of China. China has the largest state-owned tobacco industry and also the greatest number of smokers—an estimated 350 million—in the world. Each year, about 1 million people from mainland China die of tobacco-related illness.
The vast number of Chinese smokers makes the Western Pacific, despite its early ratification of the FCTC, the region with the world’s heaviest burden of tobacco-related illness. One in three of the world’s smokers lives in the Western Pacific region. It has the greatest number of smokers, the highest rates of male smoking prevalence, and the fastest increase in tobacco use by women and young people compared with the other five WHO regions.
Although China is the main contributor to the absolute numbers, some of the world’s highest rates are found in the tiny Pacific islands where tobacco use has become culturally ingrained. Chewing tobacco with the areca nut is common in the Pacific and is linked to a high incidence of, and excessively high mortality rates from, oral cancer. Worldwide, oral cancer has a 50% mortality rate, but some countries in the Western Pacific region have oral cancer mortality rates that are between 67% and 80%.
Revite Kerition, acting director of public health for Kiribati, a tiny coral island state more often associated with the struggle to survive the effects of global warming, told the meeting “tobacco is a major problem for us. 75% of men who responded to a survey were current smokers and 50% of women responders were current smokers.
“Tobacco use has gained great significance in our society. If any of you visit a village you are expected to bring a gift of tobacco to the old men of the village—also as a gift to the gods.
“The Government of Kiribati has been very careful about how it approaches the tobacco bill. Our minister of health is fighting a battle against our local gods and the highly influential old men. I’m sure you’ll agree, fighting the gods is not an easy battle.”
Tuvalu has a serious problem as well. A recent survey done there showed that tobacco is used widely, with 33% of young people saying that they use tobacco regularly.
Political change has blocked tobacco control in other nations. “The tobacco control bill has been finalised—it wasn’t passed in 2007 because I was voted out”, the Solomon Islands’ health minister, Clay Forau Soalaoi told the meeting.