civil society monitoring of the framework …...jana potúčková, stop fajčeniu, občianske...

Civil Society Monitoring of the Framework Convention

on Tobacco Control:

2007 Status Report of the Framework Convention Alliance

© Framework Convention Alliance, 2007

PRINTED IN THAILAND

© Framework Convention Alliance, 2007

PRINTED IN THAILAND

Suggested citation: Jategaonkar, N. (Ed.) Civil Society Monitoring of the Framework Convention on Tobacco Control: 2007 Status Report of the Framework Convention Alliance. Geneva: Framework Convention Alliance, 2007.

This publication is also available on the Internet at: www.fctc.org

For more information, please contact:

Framework Convention Alliancec/o ASH-DC2013 H Street, N.W.Washington, DC 20006, USA

E-mail: [email protected]

Civil Society Monitoring of the Framework Convention

on Tobacco Control:

2007 Status Report of the Framework Convention Alliance

EDITORNatasha JategaonkarProject Manager, FCA FCTC MonitorCanada

AUTHORS

IntroductionNatasha JategaonkarProject Manager, FCA FCTC Monitor Canada

Laurent HuberDirector, Framework Convention Alliance Switzerland

Chapter 1, Background InformationNatasha JategaonkarProject Manager, FCA FCTC Monitor Canada

Chapter 2, Price and Tax of Tobacco ProductsFrank J. ChaloupkaDistinguished Professor, Economics and Public Health, University of Illinois at Chicago Director, UIC Health Policy CenterUSA

Chapter 3, Protection from Exposure to Tobacco SmokeDr. Eduardo BiancoPresident, Research Center of the Tobacco Epidemic Director, Tobacco Control Program, InterAmerican Heart Foundation Uruguay

Chapter 4, Package Warnings and LabellingRob CunninghamSenior Policy Analyst, Canadian Cancer Society Canada

Chapter 5, Tobacco Advertising, Promotion, and SponsorshipJonathan LibermanPolicy Director, Framework Convention AllianceDirector, Law and Regulation VicHealth Centre for Tobacco Control and The Cancer Council VictoriaAustralia

Chapter 6, Tobacco Dependence TreatmentMartin RawFreelance consultant; Special Lecturer in Public Health Science, University of Nottingham Manager www.treatobacco.net UK

Chapter 7, Illicit Trade of Tobacco ProductsLuk JoossensAdvocacy OfficerAssociation of European Cancer Leagues, Belgium

Chapter 8, Other FCTC Initiatives(in order of appearance)Ann McNeill Chair in Health Policy & Promotion University of Nottingham UK

E. Ulysses Dorotheo, MD, FPAORegional Coordinator, Southeast Asia Tobacco Control Alliance Regional Coordinator, Framework Convention Alliance Philippines

Ana Navas-Acien, MD, PhDAssistant Professor, Department of Environmental Health SciencesJohns Hopkins Bloomberg School of Public Health USA

Chapter 9, Broader Tobacco Control IssuesShoba JohnProgramme Director, HealthBridge India

Chapter 10, The Framework Convention on Tobacco Control (FCTC) ProcessOlcott GunasekeraChairperson, Alcohol and Drug Information Centre (ADIC) Sri LankaFormer Vice President, Framework Convention AllianceSri Lanka

Conclusion, The Way ForwardAhmed E.O. OgwellDirector/Regional Coordinator for Africa Framework Convention Alliance Kenya

DATA COLLECTORS

Armenia Narine Movsisyan, American University of ArmeniaParuyr Amirjanyan, International Center for Human Development

Australia Kylie Lindorff, VicHealth Centre for Tobacco ControlStefanie Driskell, VicHealth Centre for Tobacco Control

Bangladesh Syed Mahbubul Alam Tahin, WBB Trust (Work for a Better Bangladesh) Saifuddin Ahmed, Bangladesh Anti-Tobacco Alliance (BATA)

Canada Michael DeRosenroll, Canadian Cancer Society

Fiji Luseyane Ligabalavu, Ministry of Health

Ghana Edith Wellington, Ghana Health Service

Hungary Tibor Szilágyi, Health 21 Hungarian Foundation

Iceland Viđar Jensson, Public Health Institute of Iceland

India Hemant Goswami, Burning Brain SocietyMonika Arora, Health Related Information Dissemination Amongst Youth (HRIDAY)

CONTRIBUTORS

Japan Manabu Sakuta, Japanese Society for Tobacco Control

Jordan Ziyad Alawneh, Land and Human to Advocate Progress (LHAP)

Kenya Ahmed E.O. Ogwell, Oral & Craniofacial Research Associates

Madagascar Jacques Andrianomenjanaharinirina, Office National de Lutte Antitabac (OFNALAT)

Mauritius Véronique LeClezio, ViSa Mauritius

Mexico Francisco J. López Antuñano, Alianza Contra el Tabaco, A.C.J.R. Pérez Padilla, Alianza Contra el Tabaco, A.C.Jesus F. González Roldán, Alianza Contra el Tabaco, A.C.Rafael Camacho Solís, Alianza Contra el Tabaco, A.C.Raydel Valdés Salgado, Johns Hopkins School of Public Health

Mongolia Khishigjargal Chultem, ADRA MongoliaTserennadmid Baljinnyam, Children, Youth, and Family AssociationMunk Jargal, ADRA Mongolia

New Zealand Shane Bradbrook, Te Reo Marama – Maori Smokefree CoalitionGrant Hocking, Action on Smoking and Health (ASH) New Zealand

Norway Bjarne Rosted, Norwegian Cancer Society

Pakistan Ehsan Latif, Society for Alternative Media and Research

Palau Caleb Otto, Coalition for a Tobacco Free PalauAnnabel Lyman, Coalition for a Tobacco Free Palau

Panama Reina Roa, Coalición Panameña Contra el Tabaquismo (COPACET)

Peru Carlos Farías Alburqueque, Comisión Nacional Permanente de Lucha Antitabaquica (COLAT)

Slovakia Peter Šťastný, Stop fajčeniu, občianske združenie (Stop Smoking NGO)Jana Potúčková, Stop fajčeniu, občianske združenie (Stop Smoking NGO)

Sri Lanka Olcott Gunasekera, ADIC Sri LankaManjari Peiris, Jeewaka Foundation

Thailand Sarunya Benjakul, Tobacco Control Research and Knowledge Management Center (TRC), Mahidol UniversityNuttapon Theskayan, Tobacco Control Research and Knowledge Management Center (TRC), Mahidol University

Trinidad and Tobago Caroline Alexis-Thomas, Coalition for Tobacco-Free Trinidad and Tobago

Uruguay Eduardo Bianco, Research Center of the Tobacco Epidemic

FACULTY AND STAFF OF THE INSTITUTE OF GLOBAL TOBACCO CONTROL, JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH

Erika Avila-Tang, PhD, MHSMichelle CampbellElisabeth A. Donaldson, MHSRay HamannMai-Anh Hoang, MPHLaili IraniAna Navas-Acien, MD, PhDGeorgiana OnicescuNicole PenningtonJonathan Samet, MD, MSElizabeth A. Skinner, MSWFrances Stillman, EdD, EdMSharon WhiteHeather Wipfli, MA

2007 FCA FCTC MONITOR ADVISORY COMMITTEE

Ahmed E.O. Ogwell, ChairDirector/Regional Coordinator for Africa Framework Convention Alliance Kenya

Deborah Arnott Director, Action on Smoking & HealthUK

Eduardo BiancoPresident, Research Center of the Tobacco Epidemic Director, Tobacco Control Program, InterAmerican Heart Foundation Uruguay

Fiona GodfreyEU Policy Adviser, European Respiratory SocietyBrussels

Desabandhu Olcott GunasekeraChairman, Alcohol and Drug Information Centre (ADIC) Sri Lanka Former Vice President, Framework Convention AllianceSri Lanka

Laurent HuberDirector, Framework Convention Alliance Switzerland

Shoba JohnProgramme Director, HealthBridge India

Jonathan LibermanPolicy Director, Framework Convention AllianceDirector, Law and Regulation VicHealth Centre for Tobacco Control and The Cancer Council VictoriaAustralia

Cassandra WelchManager, International Tobacco Control Programs, American Cancer SocietyUSA

Acknowledgements vi

Executive Summary vii

Introduction. Monitoring the Framework Convention on Tobacco Control (FCTC) - A Civil Society Approach 1

Chapter 1. Background Information 6

Chapter 2. Price and Tax of Tobacco Products 9

Chapter 3. Protection from Exposure to Tobacco Smoke 15

Chapter 4. Package Warnings and Labelling 24

Chapter 5. Tobacco Advertising, Promotion, and Sponsorship 37

Chapter 6. Tobacco Dependence Treatment 45

Chapter 7. Illicit Trade of Tobacco Products 52

Chapter 8. Other Framework Convention on Tobacco Control (FCTC) Initiatives 56

Chapter 9. Broader Tobacco Control Issues 74

Chapter 10. The WHO Framework Convention on Tobacco Control (FCTC) Process 81

Conclusion. The Way Forward 84

TABLE OF CONTENTS

Civil Society Monitoring of the Framework Convention on Tobacco Control: 2007 Status Report of the Framework Convention Alliance

The production of the 2007 FCA FCTC Monitor report would not have been possible without the support and commitment of many individuals and organizations. It was assembled by a dedicated team and generously supported by donors. We express our thanks to the Swedish International Development Agency (SIDA), Cancer Research UK (CRUK), Action on Smoking and Health (ASH) US, and the Open Society Institute (OSI) for their financial support.

We thank the advisory committee for the 2007 FCA FCTC Monitor project for its guidance and express our gratitude to the Framework Convention Alliance (FCA) board of directors, regional coordinators, and staff members for their leadership and support.

We thank the Institute for Global Tobacco Control at the Johns Hopkins Bloomberg School of Public Health for their partnership on this project – in particular, for the development of the data collection instrument and the supporting online data collection system, the management and analysis of the data, and the overall assistance with the preparation of the report.

We extend our special thanks to all the data collectors from across the world, for their valuable contributions to this project and for their ongoing dedication to tobacco control work.

We thank the authors for sharing their expertise and writing the individual chapters that make up this report.

We also thank expert reviewers for providing valuable input on individual chapters of the report: Madeleine Heyward, Jonathan Liberman, Ana Navas-Acien, Bungon Ritthiphakdee, and Amanda Sandford.

We thank Graphically Speaking Services Inc for designing and producing the report, and Jacqueline Larson for editing the report. We thank the Southeast Asia Tobacco Control Alliance (SEATCA) for coordinating the printing and production process in Thailand.

Natasha Jategaonkar served as the project manager and chief editor for the report’s production.

Cover images were provided by FCA members and are reproduced with permission. We thank WBB Trust (Work for a Better Bangladesh), ASH Scotland, Framework Convention Alliance (FCA), Laura Salgado, Smokefree for Kids in Japan, VicHealth Centre for Tobacco Control and Quit Victoria, Action on Smoking and Health (ASH) Australia, Saqib Sharif, and Hamidul Islam Hillol. Additional images were obtained from Microsoft Office Online.

ACKNOWLEDGEMENTS

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This is the first report of the Framework Convention Alliance (FCA) Framework Convention on Tobacco Control (FCTC) Monitor project. The FCA is a worldwide coalition of individual nongovernmental organizations and their networks who have been working to support effective tobacco control. The FCA has been involved in every stage of the FCTC, from inception to entry into force and now implementation. The FCTC is the world’s first international public health treaty, which aims to reduce the devastating health, economic, social, and environmental impact of tobacco. Negotiated under the auspices of the World Health Organization (WHO), it is a legal instrument that provides the basic tools for countries to enact comprehensive tobacco control legislation, policies, and programs at the national level. As of 25 May 2007, the FCTC has 168 signatories and 147 ratifying parties. The FCA FCTC Monitor project is a civil-society-based approach to monitor and evaluate the implementation of the FCTC and to hold governments accountable to their legal obligations under the FCTC. This first report includes data from 27 of the first 41 countries that ratified or acceded to the FCTC. The collected data assess the progress each country has made in implementing key articles of the convention, including policies regarding price and taxation (article 6); protection from exposure to tobacco smoke (article 8); packaging and labelling of tobacco products (article 11); tobacco advertising, promotion, and sponsorship (article 13); treatments for tobacco dependence (article 14); and illicit trade of tobacco products (article 15). Data are also included regarding other FCTC articles and factors outside of governments that may influence FCTC implementation.

While the majority of the 27 participating countries have passed legislation or made agreements to implement the FCTC, eight of the reports indicate that their countries have also contradicted the terms or the spirit of the FCTC. This observation speaks to the broad range of successes and challenges that the data reveal. Lack of political will and active interference by the tobacco industry are still barriers to FCTC implementation in a number of countries.

All 27 participating countries have implemented national price and tax policies on tobacco products, but many are not using price and taxation to their maximum effectiveness. Less than half of the countries have price and tax policies motivated by reducing tobacco consumption. Most countries do not regularly increase the tobacco tax rate. Only five participating countries dedicate a portion of the collected taxes specifically to health promotion (Iceland, India, Mongolia, Thailand, and Uruguay).

Most of the 27 participating countries are still not effectively protecting all their population from exposure to tobacco smoke. Only two countries, New Zealand and Uruguay, are described as having a national smoking ban in all indoor workplaces, public transport, and public places, without exceptions, and with high levels of compliance and enforcement.

Twenty-four countries have a legislated requirement for health warnings on tobacco packages. Among these, eight do not yet have warnings large enough to meet the FCTC’s 30 percent minimum standard, but eight meet or exceed the recommended 50 percent standard. Eight countries require a single warning with no rotation of any kind, and are thus not yet in compliance with article 11. One country (Mauritius) does not require the warning to be printed in the principal languages of the country. Eight of the participating countries require picture-based health warnings, which are more effective than text-only warnings. Eleven countries specifically ban the misleading cigarette descriptors “light” and “mild,” and at least three countries (Bangladesh, India, Slovakia) have sought to broaden the wording of their legislation to help curtail tobacco industry strategies. However, practical enforcement of these provisions remains a problem.

Twenty-two countries have national legislation that bans tobacco advertising, promotion, and sponsorship; however, the breadth of the legislation varies widely. The data suggest that the terms tobacco advertising and promotion and tobacco sponsorship have been interpreted in varying ways, which points to the need for guidelines on how best to implement article 13 obligations. Tobacco advertising and promotion

EXECUTIVE SUMMARY

EXECUTIVE SUMMARY

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continue to occur in many forms. Specific examples are provided for more than half of the participating countries.

Tobacco dependence treatment appears to be a low priority for many countries – 23 countries have taken steps to promote cessation of tobacco use, but only nine have measures that are comprehensive and national. While eight participating countries have a national quitline or quitlines covering all major regions, very few countries permit stop smoking medications on general sale.

The majority of participating countries experience problems with illicit trade of tobacco products but only about half of the countries have introduced legislation to reduce it.

Regarding other FCTC initiatives, the data show that most countries have inadequate and piecemeal measures related to the measurement, testing, and disclosure to governments of tobacco product contents and emissions; most countries have educational and public awareness programs on the health risks of tobacco and the benefits of tobacco cessation, but the extent of these programs varies widely; most countries prohibit sales of tobacco products to minors but enforcement is very poor; and about half of the countries have a national system for epidemiologic surveillance of tobacco consumption and related indicators.

Broader tobacco control issues also influence FCTC implementation. Many countries do not have governmental funds specifically designated for tobacco control, which in some cases is a limiting factor for meaningful civil society participation in tobacco control work. Few countries have direct public agreements with the tobacco industry, but many are vulnerable to industry influence and lobbying.

Since the FCTC entered into force, many positive developments have unfolded. However, there are some areas of concern at both the national and international levels. Priorities for the overall FCTC process include establishing the permanent COP secretariat, ensuring payment of the parties’ voluntary assessed contributions, and maintaining momentum in FCTC implementation worldwide.

Authored by individual experts in tobacco control, each chapter of this report provides an overall picture of the progress of policy and program implementation based on the collected qualitative and quantitative data, highlights examples of achievements and disappointments, and provides recommendations for how best to move forward in tobacco control.

EXECUTIVE SUMMARY

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The Framework Convention on Tobacco Control (FCTC)

Tobacco use is the leading cause of preventable death in the world today.1 With about 5 million tobacco-related deaths per year, no other consumer product is as dangerous, or kills as many people, as tobacco. In response, the international community has created the Framework Convention on Tobacco Control (FCTC), the world’s first international public health treaty.2 Negotiated under the auspices of the World Health Organization (WHO), the FCTC is an international legal instrument designed to reduce tobacco-related deaths and disease around the world. Made up of a host of measures, it is designed to reduce the devastating health, economic, social, and environmental impact of tobacco and provides the basic tools for countries to enact comprehensive tobacco control legislation, policies, and programs at the national level. The FCTC provides a multifaceted approach for protecting billions of people from the devastating impact of tobacco consumption and exposure to tobacco smoke.

Among its many provisions (see table I.1), the treaty requires countries to increase price and taxes for tobacco products; establish smoke-free indoor environments to protect populations from tobacco smoke; mandate large health warnings on all tobacco product packaging; undertake comprehensive bans on tobacco advertising, sponsorship, and promotion; and strengthen legislation to reduce the illicit trade in tobacco that makes inexpensive cigarettes easily accessible and deprives governments of billions of dollars in revenues each year.

The 192 member states of WHO unanimously adopted the FCTC at the 56th World Health Assembly, making 21 May 2003 a historic day for global public health. For the FCTC to enter into force, 40 countries had to sign and ratify it. The international community responded swiftly: within one year (i.e., by June 2004), the FCTC was

signed by 168 countries and it entered into force (on the 90th day following ratification by 40 countries) on 27 February 2005. As of 25 May 2007, the FCTC has 168 signatories and 147 ratifying parties.3

Despite the success signified by the negotiation and entry into force of the FCTC, global tobacco control still faces ongoing battles. In many countries, domestic legislation, policies, and programs are nonexistent or extremely weak, tobacco control is not perceived as a priority, the tobacco control movement is in its infancy, and the tobacco industry wields great political and economic power. Although the FCTC has been ratified in many countries, it is still not yet a reality on the ground.

For the FCTC to achieve its maximum effectiveness in saving lives, it is crucial that governments of ratifying parties live up to their commitments by implementing national tobacco control legislation, policies, and programs that comply with the FCTC and its protocols. An accountability mechanism is necessary to

INTRODUCTIONMONITORING THE FRAMEWORK CONVENTION ON TOBACCO CONTROL (FCTC) – A CIVIL SOCIETY APPROACHNatasha Jategaonkar and Laurent Huber

Article 3 Objective

Article 4 Guiding principles

Article 5 General obligations

Article 6 Price and tax measures to reduce the demand for tobacco

Article 7 Non-price measures to reduce the demand for tobacco

Article 8 Protection from exposure to tobacco smoke

Article 9 Regulation of the contents of tobacco products

Article 10 Regulation of tobacco product disclosures

Article 11 Packaging and labelling of tobacco products

Article 12 Education, communication, training and public awareness

Article 13 Tobacco advertising, promotion and sponsorship

Article 14 Demand reduction measures concerning tobacco dependence and cessation

Article 15 Illicit trade in tobacco products

Article 16 Sales to and by minors

Article 17 Provision of support for economically viable alternative activities

Article 18 Protection of the environment and the health of persons

Article 19 Liability

Article 20 Research, surveillance and exchange of information

Article 21 Reporting and exchange of information

Article 22 Cooperation in the scientific, technical and legal fields and provision of related expertise

Article 26 Financial resources

Table I.1. Summary of FCTC provisions

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ensure that the provisions of the FCTC are appropriately and effectively put into action.

Article 21 of the FCTC requires each party to submit to the Conference of the Parties (COP), through the secretariat, periodic reports on its implementation of the FCTC.4 However, at the first session of the COP in February 2006, those present agreed to a reporting system that would enable parties to learn from each others’ experience in implementation, rather than monitoring parties’ implementation of their obligations. Thus, the role of actively monitoring governments’ compliance with their obligations under the FCTC has not been undertaken by the COP. Instead, this responsibility falls primarily to nongovernmental organizations (NGOs). Due to their independence from governments, NGOs have a unique role to play in monitoring the implementation of commitments made by countries under multilateral treaties. Particularly given the limited focus of the reporting system overseen by the FCTC COP, civil society not only has the ability but also the responsibility to develop a mechanism to monitor the implementation of this first international public health treaty.

The Framework Convention Alliance (FCA)

The Framework Convention Alliance (FCA) represents a voice of civil society within the global tobacco control community.5 Founded in October 1999, the FCA is a coalition of individual nongovernmental organizations (NGOs) and their networks from around the world who have been working jointly and separately to support effective tobacco control. The FCA has been involved in every stage of the FCTC, from inception to entry into force and now implementation. In 2006, the FCA received a prestigious Luther L. Terry Award for its exemplary leadership in tobacco control. Now composed of almost 300 health, environmental, consumer, and human rights organizations from over 100 countries, the FCA continues to engage throughout the world in efforts to ensure effective implementation of the FCTC.

With 147 parties to the FCTC to date, it is crucial that civil society maintains the momentum of the convention by assisting and monitoring governments’ actions towards implementing effective tobacco control legislation, policies,

and programs at the national level. Thus, the FCA has developed the FCA FCTC Monitor, a civil-society-based approach to monitor and evaluate the implementation of the FCTC. The FCA FCTC Monitor is a mechanism created to hold governments accountable to their legal obligations under the FCTC.

The engagement of civil society in any treaty process is a key aspect of democracy and good governance. As the FCTC guiding principles state (article 4),“the participation of civil society is essential in achieving the objective of the Convention and its protocols.”6 The FCA has played a critical role in the FCTC process to date by working collaboratively with governments, providing educational material and tobacco control expertise, and helping to shape the public climate that has provided momentum for the international regulation of the tobacco industry. Having contributed to the strength of the FCTC during its early stages and encouraged governments to sign and ratify the treaty, the FCA continues to play a critical role in its monitoring of the implementation by governments of the obligations to which they have committed. The release of Civil Society Monitoring of the Framework Convention on Tobacco Control: 2007 Status Report of the Framework Convention Alliance, the first report of the FCA FCTC Monitor project, marks the beginning of this important process.

The FCA FCTC Monitor

Created by civil society representatives in recognition of the importance of article 21 of the FCTC, the FCA FCTC Monitor complements the required party reporting with much-needed independent reporting, monitoring, and evaluation. All elements of the FCA FCTC Monitor process, from formulating and posing the questions to commenting on the collected data, are driven by civil society. Our first report, Civil Society Monitoring of the Framework Convention on Tobacco Control: 2007 Status Report of the Framework Convention Alliance, identifies specific gaps and successes of FCTC implementation in 27 countries around the world (listed and described in table I.2), based on data and input from NGO data collectors. Chapters of this report, each addressing a specific article of the FCTC, have been written by individual experts in tobacco

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control. Each chapter provides an overall picture of the progress of policy and program implementation based on the collected data, highlighting examples of achievements and disappointments, and offers recommendations on how existing gaps can be addressed, based on the FCTC, the data of the 2007 FCA FCTC Monitor, and the expertise and experience of individual authors. We intend this report to serve as an advocacy tool, which will be widely distributed to encourage greater international compliance with FCTC commitments. This year’s report will provide a baseline of information that will allow comparisons over time.

The Data Collection System

The FCA FCTC Monitor data collection system was developed in partnership with the Institute for Global Tobacco Control of the Johns Hopkins Bloomberg School of Public Health, with assistance from international experts. It is an Internet-based system that allows data collectors from countries all over the world to enter data about the implementation of FCTC provisions in their particular countries directly into one database. Each country’s data collector receives a specific username and password in order to enter collected data, including assessments of tobacco policy information (e.g., policies regarding tobacco smoke, advertising, warning labels, taxation), as well as factors outside of governments that may influence implementation (e.g., tobacco industry, intergovernmental organizations). The instrument records both quantitative data and qualitative descriptions of current tobacco control activity within individual countries. Data collection is conducted at the national level by members of civil society and NGOs for most countries. In some cases, government officials participate when tobacco control NGOs are not present in the country or are not able to participate. The FCA FCTC Monitor data collection system was pilot tested in 2006 with the participation of data collectors in seven countries and it was then revised based on the feedback received.

The final FCA FCTC Monitor data collection instrument for 2007 includes six sections, each assessing implementation of a specific article in detail (article 6, price and tax measures; article 8, protection from exposure to tobacco smoke;

article 11, packaging and labelling of tobacco products; article 13, tobacco advertising, promotion, and sponsorship; article 14, tobacco dependence and cessation; and article 15, illicit trade in tobacco products). A separate section briefly addresses remaining FCTC articles, with the intention that further details on these topics may be included in subsequent editions of the monitor, and another section includes assessments of factors outside of governments that may influence FCTC implementation, such as interference by the tobacco industry and the role of NGOs in tobacco control work. Each of these sections incorporates questions that are “multiple choice” or require some quantitative assessment of the situation within a country, but they also include open-ended questions where data collectors are encouraged to provide a description in their own words. In some sections, data collectors are asked to upload specific documents such as photos or legislation documents. A final section, “Beyond the Numbers,” allows data collectors to describe their national situations beyond the responses to individual questions and to provide background on key issues that might not have been addressed elsewhere in the questionnaire. The data collection instrument thus provides a depth of information regarding underlying political, economic, and social processes in the countries surveyed and visible outputs such as policy texts and enforcement practices.

The questionnaire that was used to collect the data forming the basis for Civil Society Monitoring of the Framework Convention on Tobacco Control: 2007 Status Report of the Framework Convention Alliance is available online at http://www.fctc.org.

The Data Collection Process

For this first report, we sought to include the first 41 countries to ratify or accede to the FCTC. We used the existing extensive networks of the FCA to engage individuals and organizations around the world who are leaders in tobacco control activity. All organizations that expressed interest in participating in the FCA FCTC Monitor project on behalf of the civil society tobacco control community of their country were asked to submit a formal application detailing their experience and expertise. In some countries, there were several

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organizations interested and available to participate — in such cases we encouraged internal collaborative processes. In general, each organization (or coalition of organizations) appointed one or two individuals to act as the key informant or representative for the data collection and data entry processes. Organizations in low-, lower-middle-, and upper-middle-income countries received a stipend of 1000 USD for participating.

Data collection began for some countries in December 2006, while others joined the project later. All data entry was completed by April 2007. The experience of collecting and entering the data into the database varied for organizations around the world, depending largely on the availability of the information in the respective countries. Data collectors found some questions easy to respond to for their countries, while the same questions were difficult for others. In some cases, data collectors could rely on well-documented research and reports to answer the questions, while in other cases, data collectors made use of media, interviews, and their own expert experience to draw conclusions. In all cases, data collectors were asked to make use of the best available information in their country to respond to the questions. For those questions where the information was not available, data collectors indicated “unable to determine” in the database.

A data review process was undertaken in April 2007 to confirm with data collectors the details of the data submitted, although the data were not formally validated. The data review and analysis processes were led by the team from the Institute for Global Tobacco Control of the Johns Hopkins Bloomberg School of Public Health in collaboration with the FCA. After data collectors had entered and saved the complete data for their respective countries, the responses were reviewed for completeness and consistency. Queries about unclear responses were directed to data collectors, and corrections were made in the database accordingly. This final dataset formed the basis for the data analysis reported here.

The First Report

Although our goal was to include data from the first 41 countries that ratified or acceded to the FCTC, data collectors from 27 participated in the 2007 FCA FCTC Monitor (see table I.2). Organizations from several of the remaining 14 countries also expressed interest in participating, but were unable to commit to data collection this year due to other competing time pressures. We look forward to ongoing collaboration and inclusion of these countries in subsequent editions of the FCA FCTC Monitor.

Table I.2. Countries participating in the Civil Society Monitoring of the Framework Convention on Tobacco Control: 2007 Status Report of the Framework Convention Alliance, by World Health Organization region and by World Bank country groupings by income7,8

Legend: LI = Low-income economy, LMI = Lower-middle-income economy, UMI = Upper-middle-income economy, HI = High-income economy.

Africa (AFR)

1 Ghana (LI)

2 Kenya (LI)

3 Madagascar (LI)

4 Mauritius (UMI)

Americas (AMR)

5 Canada (HI)

6 Mexico (UMI)

7 Panama (UMI)

8 Peru (LMI)

9 Trinidad and Tobago (UMI)

10 Uruguay (UMI)

Europe (EUR)

11 Armenia (LMI)

12 Hungary (UMI)

13 Iceland (HI)

14 Norway (HI)

15 Slovakia (UMI)

Eastern Mediterranean (EMR)

16 Jordan (LMI)

17 Pakistan (LI)

Southeast Asia (SEAR)

18 Bangladesh (LI)

19 India (LI)

20 Sri Lanka (LMI)

21 Thailand (LMI)

Western Pacific (WPR)

22 Australia (HI)

23 Fiji (LMI)

24 Japan (HI)

25 Mongolia (LI)

26 New Zealand (HI)

27 Palau (UMI)

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Notes1. World Health Organization. An international treaty for tobacco control. 12 August 2003. Retrieved 17 May 2007 from: http://

www.who.int/features/2003/08/en2. World Health Organization. Framework Convention on Tobacco Control (FCTC). Geneva: WHO, adopted 16 June 2003, entered

into force 27 February 2005. Available at: http://www.who.int/tobacco/framework/en3. World Health Organization. Updated status of the WHO Framework Convention on Tobacco Control. Retrieved 25 May 2007 from:

http://www.who.int/tobacco/framework/countrylist/en/index.html4. The Conference of the Parties (COP) is the regulating body of the FCTC, and decides in detail the procedural, financial, and

reporting matters, among others, relating to the implementation of the convention.5. For more information on the FCA and its members, please see http://www.fctc.org/ 6. World Health Organization. Framework Convention on Tobacco Control. Guiding principles, article 4 (p. 6). Retrieved 25 May

2007 from: http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf 7. World Health Organization. Tobacco Free Initiative. Retrieved 17 May 2007 from: http://www.who.int/about/regions/en/index.html 8. World Bank. Development data and statistics. All countries by groups. Retrieved 23 May 2007 from: http://www.worldbank.org/ 9. World Health Organization. WHO Framework Convention on Tobacco Control (WHO FCTC). Retrieved 17 May 2007 from: http://

www.who.int/tobacco/framework/en

Together, this subset of 27 of the first ratifying parties to the FCTC (referred to in this report as “the participating countries”), represent an emblematic sample of both the challenges and successes of FCTC implementation in countries around the world. The 27 countries represented in this report include a range of diverse economic and geographic contexts for FCTC implementation, with participating countries from all four World Bank country groupings by income and all six World Health Organization regions (see Table I.2), although they are not intended to be a perfectly representative sample of the first 41 ratifying countries.

This report has 10 chapters that address key elements of the FCTC and its implementation on the ground. Chapter 1 sets the context for the report by providing background information on individual countries, including their tobacco control priorities and their participation in the work of the COP to date, as well as descriptions of the data collectors who report for the FCA FCTC Monitor. Chapters 2 to 7 each assess the implementation of a specific article in detail. Written by an individual expert within the corresponding area of tobacco control, each chapter provides a synthesis of both the numerical and descriptive data collected, and generates recommendations on how tobacco control efforts can be moved forward in each area. Some authors provide broad recommendations beyond the collected data. Countries deserving special compliments or critiques are also highlighted. Chapter 8 follows a similar structure, addressing the remaining FCTC articles more briefly, but also with recommendations and country highlights. Chapter 9 summarizes the data collected on non-party factors that may influence FCTC implementation, such as interference by the

tobacco industry and the role of NGOs in tobacco control work. Finally, chapter 10 does not rely directly on collected data, but instead draws from broad expertise to provide a global commentary on the implementation of the treaty and the processes of the COP.

Every chapter reflects the diverse experiences of tobacco control work in countries around the world, as well as the differences in its impact. However, quantitative or categorical comparisons across countries were not always possible. In analyzing the data, we discovered many different interpretations of some of the questions posed in the 2007 FCA FCTC Monitor. In particular, terms such as adequate, sufficient, complete, and moderate, which are inherently subjective, proved difficult to make consistent. Where this problem occurs, responses in this report are instead noted in the qualitative or descriptive terms provided by the data collectors themselves, although the level of detail provided by data collectors also varies from one country to another. Above all, Civil Society Monitoring of the Framework Convention on Tobacco Control: 2007 Status Report of the Framework Convention Alliance is a tool to learn from. This report contains a rich collection of examples, illustrations, and anecdotes from countries around the world, that bring to the fore the need for strong and detailed policies, programs, and legislation documents to reflect FCTC commitments and save lives. We have a lot of work ahead of us. As the former director-general of the WHO, Dr. Jong-Wook Lee reminds us, “the success of the WHO FCTC as a tool for public health will depend on the energy and political commitment that we devote to implementing it, in countries in the coming years.”9

INTRODUCTION

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Parties to the Framework Convention on Tobacco Control (FCTC) have agreed that the general obligations (article 5) underpinning the treaty include the development, implementation, and periodic update and review of “comprehensive multisectoral national tobacco control strategies, plans and programs” in accordance with the FCTC and its protocols. This chapter first provides background information on the organizations that worked as data collectors in each participating country. It then describes the tobacco control priorities of the 27 countries participating in the 2007 FCA FCTC Monitor, including the improvements that have already been achieved, the issues that require further work, and the countries’ participation in the first session of the Conference of the Parties (COP).

Background Information on Participating Organizations

The majority (22 out of 27) of the participating organizations are nonprofit, and four are government organizations (Fiji, Ghana, Iceland, and Madagascar). One organization, reporting for Thailand, describes itself as an academic centre for tobacco control research. The participating organizations vary in their tobacco control focus. Approximately half (13 out of 27) of the participating organizations focus entirely on tobacco control activities. The others range in their level of focus on tobacco control activities, with six of the organizations saying that only a small proportion of their organization focuses on tobacco control activities (Armenia, Canada, Iceland, Jordan, Mongolia, and Norway), and another eight saying that tobacco control activities represent somewhere between 25 and 99 percent of their work (Bangladesh, Fiji, Ghana, Hungary, India, Kenya, Madagascar, and Sri Lanka).

Background Information on FCTC Implementation in the Participating Countries

The majority (22) of the data collectors from the 27 participating countries report that their country has passed legislation or made agreements to implement the FCTC since ratification or accession (see table 1.1). However, eight of them also report that their country has passed legislation or made

agreements that contradict the terms or “spirit” of the FCTC. Among these eight countries, there is some variation in the types of legislation or agreements that contradicted the FCTC. Data collectors from a few countries report decreases in taxes on tobacco products – for example, in Mauritius, excise taxes on imported cigarettes decreased in 2006; and in Mongolia, the revised Law of Mongolia on Value-Added Tax (effective 1 January 2007) means that value-added tax (VAT) was decreased from 15 percent to 10 percent on all imported and manufactured goods, which unfortunately include tobacco. Other examples of contradictory legislation/agreements include a report from Australia explaining how requirements to apply specific identifying markings to packages of tobacco products have been repealed via the Excise Laws Amendment (Fuel Tax Reform and Other Measures) Act, 2006; and a report from Norway that the government currently has funds invested in the tobacco industry through the Norwegian government pension fund. In Canada, some bylaws have been permitted in breach of article 8 (protection from exposure to tobacco smoke) (see box on next page for further examples). Even among countries where data collectors report that their governments have not made agreements that contradict the FCTC, at least one data collector notes that the issue requires continuous surveillance because of the tobacco industry’s past record of influencing certain government sectors. The majority of countries (25) participated in the first session of the Conference of the Parties (COP) (Geneva, 6-17 February 2006) as parties. Only two countries (Iceland and Trinidad and Tobago) did not participate at all. Among the 25 countries that participated in that first COP session, more than half of data collectors (13) describe their countries’ involvement as “high,” meaning that the country in question actively intervened in discussions and commented on most or all of the issues presented.

Each data collector was asked to characterize their country’s stance on a number of aspects related to the FCTC. In general, data collectors report their governments to be “supportive,” with over half reporting favourable support for development of a protocol or protocols to the FCTC (data collectors from 14 participating countries) and funding provisions for FCTC

CHAPTER 1 BACKGROUND INFORMATIONNatasha Jategaonkar

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implementation (data collectors from 14 participating countries). Data collectors in 18 of the 25 countries who participated in the first session of the COP report that their governments are supportive of formal civil society involvement in tobacco control. Interestingly, data collectors characterize only 10 countries as supportive of strong reporting requirements for implementation of the FCTC.

Country data collectors were also asked to describe, in several open-ended questions, their countries’ achievements and needs for improvement with respect to FCTC implementation. Achievements were many and varied around the globe. Most data collectors cite the adoption and/or implementation of new policies that address major provisions of the FCTC, such as price and tax (article 6), protection from exposure to tobacco smoke (article 8) and tobacco advertising, promotion, and sponsorship (article 13). In other countries, opportunities for collaboration and communication within governments represent major achievements – in Pakistan, an interministerial committee has been set up to oversee progress on tobacco control,1 and similarly in Japan an interministry board meeting for FCTC implementation has taken place.2

It seems significant that two key barriers to implementing FCTC provisions appear to be shared experiences by many participating countries worldwide: lack of political will and influence by the tobacco industry. The latter takes many forms—in Kenya, the tobacco

industry interferes with legislative processes,3 whereas in Palau, many elected officials are business owners who sell tobacco and many are also users of tobacco products.4 Further examples of both the achievements and challenges of FCTC implementation that are noted in the monitor are detailed in the box below.

Conclusion

A range of different organizations participated in the 2007 FCA FCTC Monitor, with the majority describing themselves as nonprofit. Some organizations’ entire focus is in tobacco control work, but the majority work on tobacco control in addition to other areas. Descriptions of countries’ priorities in tobacco control show that successes in FCTC implementation often occur alongside disappointing legislation or agreements that contradict the spirit of the FCTC. It is promising that data collectors from approximately half of the countries participating in the 2007 FCA FCTC Monitor describe their countries as “supportive” of a number of aspects related to the FCTC and also have diverse achievements in FCTC implementation to report. The experiences of barriers to FCTC implementation tend to be shared by many countries. In sum, the 27 countries participating in Civil Society Monitoring of the Framework Convention on Tobacco Control: 2007 Status Report of the Framework Convention Alliance represent a wide range of unique contexts and situations that form the backdrop for FCTC implementation.

• In Fiji, there have been several improvements to tobacco control policy since ratifying the FCTC, including a newly established Tobacco Control Enforcement Unit. Government support for and public awareness of tobacco control issues have both been increasing, but there is currently a need in the country for external support in developing cessation programs.5

• In Mauritius, the international airport, the municipality of Port Louis, and many shopping centres have voluntarily implemented smoke-free policies, and the British American Tobacco (BAT) Mauritius factory was closed in 2006 after an 80-year presence in the country.6

• In Canada, the poor state of relations between federal and provincial governments and Aboriginal governments is a major barrier to reducing tobacco use among Aboriginal communities. Smoking rates are almost three times higher among Aboriginal

people than in the population as a whole. Several First Nations (local Aboriginal jurisdictions) have passed bylaws permitting smoking in certain public places, which has resulted in the loss of protection from tobacco smoke previously enjoyed by people in the affected communities. The federal Minister of Indian and Northern Affairs is responsible for reviewing and approving First Nation bylaws. The federal government’s failure to disallow these bylaws is a breach of article 8 of the FCTC.7

• In Ghana, a five-year plan of action was developed for the Ghana Health Service. Priority areas include action items such as campaigns to raise public awareness about tobacco control issues and a national study to determine the prevalence of smoking among the adult population. However, the bill is yet to be submitted to parliament, and hopefully the government will allocate sufficient funds for tobacco control when the tobacco bill is passed and becomes law.8

Further examples of achievements, priorities, and challenges in FCTC implementation among countries participating in the FCA FCTC Monitor

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Notes1. Data collector for Pakistan, personal communication from E. Latif, Society for Alternative Media and Research, 20

March 2007, based on personal participation on these committees and summaries of official documents reported in the National Gazette.

2. Data collector for Japan, personal communication from M. Sakuta, Japanese Society for Tobacco Control, 20 March 2007, based on articles and translated homepage of Ministry of Health, Welfare, Labour. Available at http://www.mhlw.go.jp/english/index.html

3. Data collector for Kenya, personal communication from A. Ogwell, Oral and Craniofacial Research Associates, 4 April 2007, based on experiences of reporters with tobacco control activities.

4. Data collectors for Palau, personal communication from C. Otto and A. Lyman, Coalition for a Tobacco Free Palau, 15 March 2007, based on Palau voting records, observations of congressional debates, congressional journals.

5. Data collector for Fiji, personal communication from L. Ligabalavu, Ministry of Health, 25 March 2007.6. Data collector for Mauritius, personal communication from V. LeClezio, ViSa Mauritius, based on Ministry of Health and

Finance and National Planning records; BAT arrête la production locale de cigarettes [BAT shuts down], L’express 7 November 2006. Available at: http://www.lexpress.mu/display_search_result.php?news_id=75566 Municipality of Port Louis goes smoke free. Retrieved (date unknown) from: http://www.tobacco.org/articles/country/mauritius/

7. Data collector for Canada, personal communication from M. DeRosenroll, Canadian Cancer Society, 23 March 2007. Based on smoking rates obtained from the Canadian Cancer Society, National Aboriginal Health Association, and Canadian Tobacco Use Monitoring Survey.

8. Wellington, E. Draft five-year plan of action for tobacco control. Presentation to Health Canada, Ottawa, December 2006.

Legend: Y=Yes, N=No, U=Unable to determine, X=Not applicable, H=High, M=Moderate, L=Low to none, S=Supportive, E=Neutral, C=Contrary

Table 1.1. FCTC Implementation and participation in Conference of the Parties (COP)

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Extensive research from high-income countries and growing research from low- and middle-income countries has clearly demonstrated that increases in taxes and prices for cigarette and other tobacco products are very effective in reducing tobacco use. Increases in tax and price promote cessation among current tobacco users, prevent initiation among potential users, keep former users from restarting, and reduce consumption among those who continue to use tobacco. Researchers estimate that a 10 percent increase in price reduces overall consumption by approximately 4 percent in high-income countries and by twice as much in low- and middle-income countries. Tobacco use among younger people and those on lower incomes is particularly responsive to increases in taxes and prices.1,2,3,4

Provisions of the FCTC that Address Price and Tax Measures – Article 6

According to article 6 of the Framework Convention on Tobacco Control (FCTC), “the Parties recognize that price and tax measures are an effective and important means of reducing tobacco consumption by various segments of the population, in particular young persons” (6.1). Under this article, parties agree that they will adopt or maintain, as appropriate, price and tax measures which may include: tax and price policies on tobacco products “so as to contribute to the health objectives aimed at reducing tobacco consumption” (6.2a); and prohibitions or restrictions on “sales to and/or importations by international travellers of tax- and duty-free tobacco products” (6.2b). As part of article 6, parties are required to report tax rates and trends in tobacco consumption to the Conference of the Parties. In acknowledgement of the potential for illicit trade to undermine the effectiveness of tobacco tax and price policies in reducing consumption, article 15 of the FCTC also calls for the adoption and implementation of measures aimed at eliminating illicit trade in tobacco products (see chapter 7 for a discussion of article 15).

An analysis of tobacco taxation and pricing can be quite complex because different forms of tobacco in various stages of distribution and at different political levels are involved. Taxes can be applied to unprocessed tobacco leaf as well as to a wide variety of tobacco

products, and can be based on some measure of quantity (e.g., weight or number of units) and/or based on a measure of value. Imports and/or exports of both tobacco leaf and tobacco products can be subject to tax, as can different points in the distribution process, including manufacture, wholesale distribution, and retail sale. In addition to national taxes, subnational taxes are applied in many countries (e.g., at the state or provincial level). While the FCTC allows governments to tax tobacco and tobacco products and to regulate prices (for example, some governments specify minimum prices for various tobacco products), article 6 of the FCTC does not provide specific guidance on the level of taxes or prices, the share of tax in price, the structure and/or implementation of taxes, or other relevant aspects of tobacco taxation and pricing. Rather, the FCTC recognizes the “sovereign right” of the parties to determine and establish their own taxation policies.

Types of Tobacco Taxes

There are four key types of tobacco taxes: customs duties, excise taxes, sales taxes, and value-added taxes which are briefly explained here in table 2.1.

Table 2.1. Types of taxes applied to tobacco products

CHAPTER 2 PRICE AND TAX OF TOBACCO PRODUCTSFrank J. Chaloupka

Types of taxes Definition

Customs duty A tax on imports and/or exports, typically applied on a wide range of products, but may include additional levies on particular products

Excise tax A tax on selected goods produced for sale within a country or imported and sold in that country; can be specific (based on quantity or weight, independent of price) or ad valorem (assessed as a percentage of price)

Sales tax A tax on a broad range of goods and services sold within a country, generally assessed at the point of sale to consumers and as a percentage of the retail price

Value-added tax (VAT) A general, indirect tax on consumption that is applied at each stage of production and distribution based on the value added to the product at that stage

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Although these taxes can be applied to tobacco leaf, the FCTC focuses on the taxation of tobacco products and so this chapter similarly concentrates on such products. These taxes can be imposed at different points in the distribution process. For example, manufacturers typically pay the national excise taxes imposed on tobacco products; in countries where subnational excise taxes can be applied, they are often paid by the relatively small number of wholesalers who distribute tobacco products to retailers within the relevant subnational jurisdiction. Some taxes will include other taxes in the base upon which they are applied; for example, the sales or value-added taxes in many countries include the excise taxes that were applied earlier in the distribution process.

Of the various forms of tobacco taxation, excise taxes are the most important because, unlike the others that are typically applied to a wide variety of consumer goods and services, excises are applied to only a few specific products (like alcoholic beverages and motor fuels, in addition to tobacco products). Tobacco product excise taxes can be “specific” taxes — those based on a measure of quantity (e.g., number of cigarettes) — or ad valorem taxes, which are based on a measure of value (e.g., manufacturers’ prices); some countries employ a combination of both. The choice of excise has important implications for tobacco product pricing, government revenues, and the mix of tobacco products consumed. For example, in the presence of inflation, specific taxes will lose their value over time unless they are regularly increased, while ad valorem taxes will be more likely to keep pace with inflation. As part of their tobacco tax policy, countries can require regular increases in their specific tax rate to avoid the erosion of the tax by inflation; however, only a few of the participating countries (Australia and New Zealand) have done this.5 The revenues generated from specific taxes, however, will generally be more stable and predictable than those generated by ad valorem taxes, which can vary based on

industry pricing strategies. Ad valorem taxes typically result in a larger difference in prices between more expensive and less expensive products and, as a result, are likely to lead to greater availability and consumption of low-quality products. Some countries apply different specific or ad valorem tax rates to different types of a given product (e.g., filtered and unfiltered cigarettes, premium and discount cigarettes) which can increase this price gap. Some countries specify minimum taxes in an effort to at least partially reduce the gap between low- and high-priced products. Sunley and his colleagues6 and Yurekli and de Beyer7 provide more complete discussions of the issues concerning the design and administration of tobacco excise taxes.

Findings from the 2007 FCA FCTC Monitor: Which Countries Have National Tobacco Product Price and Tax Policies?

Data collectors from all of the 27 countries participating in the 2007 FCA FCTC Monitor indicate that their countries have implemented national tobacco product tax and price policies. Data collectors from 12 of the participating countries indicate that the policies are motivated by reducing tobacco consumption whereas revenue generation is the most likely motive in the other 15 countries. Responses are summarized in table 2.2.

With the exception of Japan, all of the data collectors from participating high-income countries indicate that their tobacco tax/price policies aim to reduce tobacco consumption (Australia, Canada, Iceland, New Zealand, and Norway). Other countries who use their tobacco tax to reduce consumption include mostly a mix of low-income (Mongolia, Pakistan), and upper-middle-income countries (Mauritius, Mexico, Slovakia, Uruguay).

Table 2.2. Countries’ motives for national tobacco product tax/price policies, by WHO region

AFR AMR EMR EUR SEAR WPR

To reduce consumption (n=12)

Mauritius CanadaMexicoUruguay

Pakistan IcelandNorwaySlovakia

Thailand AustraliaMongoliaNew Zealand

For other purposes(n=15)

GhanaKenyaMadagascar

PanamaPeruTrinidad & Tobago

Jordan ArmeniaHungary

BangladeshIndiaSri Lanka

FijiJapanPalau

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Data collectors from countries that have a national tobacco product tax policy for purposes other than reducing tobacco consumption often indicate that tobacco product taxes are meant to generate revenues. For example, the report from India states that “the objective of all taxes is to generate additional revenue”8 while the report from Palau claims that “taxes are used for general revenue funds; therefore the incentive is to collect more taxes for general operations and not really for reduction of tobacco consumption.”9 Similarly, the report from Bangladesh states that “the government does of course tax tobacco, but the goal seems to be government revenue, not reducing use, and the taxes have remained low for years, resulting in an actual decline in price. There are no price laws or regulations or policies to keep the price of tobacco high.”10

In two of the countries indicating that the tax is used to discourage tobacco consumption, data collectors note that the tax serves the dual purpose of also increasing revenue. The data collector from Australia notes that its tobacco control strategy endorses tobacco taxation as a key regulatory tool to discourage consumption, but it is assumed that the tobacco excise regime exists to fulfill additional objectives, including public revenue raising,11 while the data collector from Hungary states that “the government uses both arguments: health and generating budget incomes.”12 Of course the two objectives can be considered consistent because higher tobacco taxes both discourage tobacco consumption and increase revenues. At some point, however, increased taxes may lead to large enough reductions in tobacco consumption that tobacco tax revenues will fall, although this has not yet occurred anywhere. In the very few cases that revenues have fallen following a tobacco tax increase, it has been the result of increased illicit trade in tobacco products, not large reductions in tobacco consumption.13

Tobacco Tax Structures

The types and levels of taxes applied to tobacco products vary considerably in the 27 participating countries. Some countries employ a relatively simple tax structure. For example, Norway applies a specific excise tax of NOK

1.87 (.31 USD) per gram to all cigarettes, cigars, and loose tobacco and a specific tax of NOK 0.60 (.10 USD) per gram to snuff and chewing tobacco, while Mexico imposes an ad valorem excise tax of 140 percent of wholesale price on all cigarettes.14 Others have excise tax rates that vary based on the characteristics of the product, including its production location (domestically produced or imported), whether it is filtered or unfiltered, its length, and its price. For example, Armenia imposes different taxes on imported brands and domestically produced brands of cigarettes,15 while India and Sri Lanka impose higher excises on longer manufactured cigarettes.16

Some countries employ a mix of both specific and ad valorem excise taxes in an effort to minimize the disadvantages of each. For example, Slovakia applies a specific tax of 1.10 SKK (.43 USD) per cigarette and an additional ad valorem tax of 23 percent of the suggested retail price (the price on the tax stamp), with a minimum combined tax of 1.70 SKK (.67 USD) per cigarette.17 In efforts to address inflation’s potential to erode the value of a specific tax (the primary disadvantage of this type of excise tax), some countries that apply only specific taxes also include provisions that call for regular increases in the tax. For example, Australia adjusts its tax every six months while New Zealand adjusts its tax annually.18 Mongolia applies a tax of .60 USD per 100 cigarettes and cigars and then adjusts it based on the current exchange rate between the local currency and the US dollar.19

Five participating countries dedicate a portion of the taxes collected on tobacco products specifically to health promotion: Iceland, India, Mongolia, Thailand, and Uruguay.20 A few others also earmark tobacco tax revenues, but for other activities. For example, Japan earmarks a portion for the settlement of the debt of Japan National Railway while Madagascar dedicates some revenue to sport promotion.21 Reports from other countries, such as Australia and Kenya, note that tobacco tax revenues go into general revenues and that funding for tobacco control and/or health promotion activities are supported from these general revenues as part of the budget-making process.22

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Subnational Tobacco Product Taxes

Of the 27 participating countries, data collectors from only two report having subnational taxes – Canada and Thailand. In Canada, provincial governments tax cigarettes at rates that exceed the national cigarette tax of about .08 CAD per cigarette. There is considerable variance in the provincial tax rates, from a low of about .10 CAD per cigarette in Quebec to a high of .21 CAD per cigarette in the Northwest Territories and Nunavut.23 In contrast, local cigarette taxes in Thailand are the same across all localities (1.83 baht, approximately .56 USD per pack).24

Restrictions on Duty-Free Sales and/or Importation

Two participating countries ban all duty-free tobacco product sales and importation – Hungary and Madagascar. In Hungary, the ban was in response to an EU directive; details were not provided for Madagascar.25 Data collectors from six countries report no limits on the sale or import of duty-free products

– Bangladesh, Jordan, Mexico, Pakistan, Palau, and Uruguay. The remaining countries (with the exception of Peru for which the policy could not be determined) impose some limit on duty-free tobacco products. These limits are typically specified as a maximum number of units that can be obtained for personal consumption. For example, Kenya limits international travellers “to personal consumption levels of a maximum of one dozen packets” while New Zealand allows “200 cigarettes or 250 grammes of tobacco or 50 cigars or a combination of any of these products weighing not more that 250 grammes for each passenger aged 17 years and over.”26

Cigarette Prices

In general, data collectors from participating countries report considerable variation in cigarette prices for different brands within their countries. In India, for example, Marlboro prices are nearly 18 times the price of the cheapest available brand while the most popular local brand is almost four-and-a-half times as expensive as the cheapest brand.27 In a few

$0.00 $2.00 $4.00 $6.00 $8.00 $10.00 $12.00

BangladeshGhanaIndia

KenyaMadagascar

MongoliaPakistanArmenia

PeruSri LankaThailandHungary

MauritiusMexico

PalauPanamaSlovakia

Trinidad & TobagoUruguayAustralia

IcelandJapan

New ZealandNorway

Cheapest Brand Most Popular Local Brand Marlboro

Low-Income

Lower-Middle-Income

Upper-Middle-Income

High-Income

Figure 2.1. Cigarette prices (in US dollars per pack of 20) Cheapest, most popular local, and Marlboro brands

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Notes1. Jha, P., Chaloupka, F.J., Moore, J., Gajalakshmi, V., Gupta, P.C., Peck, R., Asma, S., & Zatonski, W. Tobacco addiction.

In D.T. Jamison & J.G. Breman, et al. (Eds.), Disease control priorities in developing countries (2nd ed., pp. 869-885). Washington DC: International Bank for Reconstruction and Development/World Bank, 2006.

2. Ross, H., & Chaloupka, F.J. Economic policies for tobacco control in developing countries. Salud Pública de México 2006; 48(Suppl. 1): 113-120.

3. Chaloupka, F.J., Hu, T.W., Warner, K.E., Jacobs, R., & Yurekli, A. The taxation of tobacco products. In P. Jha & F.J. Chaloupka (Eds.), Tobacco control in developing countries (pp. 237-272). Oxford: Oxford University Press, 2000.

4. Jha, P., & Chaloupka, F.J. Curbing the epidemic: Governments and the economics of tobacco control. Washington DC: International Bank for Reconstruction and Development/World Bank, 1999.

5. Sunley, E. Tobacco excise taxation in Asia: Recent trends and developments. Manuscript prepared for the fourth meeting of the Asia Tax Forum, Hanoi, Vietnam, 2007.

6. Sunley, E., Yurekli, A., & Chaloupka, F.J. The design, administration, and potential revenue of tobacco excises. In P. Jha & F.J. Chaloupka (Eds.), Tobacco control in developing countries (pp. 409-426). Oxford: Oxford University Press, 2000.

countries such as New Zealand and Norway, there was little difference reported in prices among brands.28

Figure 2.1 illustrates cigarette prices in the 24 countries for which data collectors report prices. Data collectors from three participating countries (Canada, Fiji, and Jordan) did not report prices. The prices in figure 2.1 include prices for Marlboro (the most commonly reported international brand), the most popular local brand (which varies from country to country), and the least expensive available brand (which also varies from country to country). Most prices were reported in units of the local currency, although a few were reported in US dollars and one in Canadian dollars. For comparison, prices were converted to US dollars based on the exchange rates reported by OANDA on 7 May 2007.29

In the 24 countries reporting prices for the most popular local brand, prices range from a low of USD 0.43 in Mongolia to a high of USD 11.03 in Norway. Similar variations were observed for prices of the least expensive brand available and in Marlboro prices. Five of the 24 countries have a brand available for less than USD 0.30 per pack, while half of the reporting countries (12) have a brand available for less than USD 1.00 per pack. Of the international brands asked about (Marlboro, Camel, Winston, L&M, and Mild Seven), Marlboro was the most commonly reported (in 20 of the 24 countries reporting prices). Prices for Marlboro and other international brands were less likely to be reported in low-income countries, most likely due to the unavailability of these brands in the lowest income countries. Prices were generally highest in high-income countries and fell with income across countries. For example, the

median price of the most popular local brand was USD 0.67 in low-income countries, USD 1.06 in lower-middle-income countries, USD 1.98 in upper-middle-income countries, and USD 7.21 in high-income countries.

Conclusions and Recommendations

Increases in tobacco taxes are highly effective in reducing tobacco use, but many participating countries – particularly low- and middle-income countries – are not yet using tobacco taxation for this purpose. 1. Given the FCTC article 6 call to tax tobacco

in order to reduce tobacco consumption, it is crucial that countries adopt tobacco tax policies that aim to reduce tobacco use.

2. High specific tobacco excise taxes that are

regularly adjusted to increase more rapidly than inflation would be most effective in reducing tobacco use and its public health consequences. Many countries still employ either ad valorem excise taxes or a mix of specific and ad valorem taxes, and very few of those with specific taxes regularly adjust their tax rate to account for inflation.

3. Higher tobacco taxes will generate significant

new revenues, at least in the short to medium term. To date, however, few participating countries dedicate some portion of tobacco taxes to health promotion efforts, including efforts to curb tobacco use. To the extent allowable, dedicating a portion of the new revenues generated from tobacco tax increases to tobacco control programs would add to the public health impact of higher tobacco taxes.

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7. Yurekli, A., & de Beyer, J. Tool 4. Design and administration: Design and administer tobacco taxes. Washington DC: International Bank for Reconstruction and Development/World Bank, 2002. Available at: http://siteresources.worldbank.org/INTETC/Resources/375990-1113490055569/Taxes.pdf

8. Personal communication from H. Goswami, Burning Brain Society. Based on Union budget 2005-2006, Ministry of Finance, India.

9. Personal communication from C. Otto and A. Lyman, Coalition for a Tobacco Free Palau, 15 March 2007. Based on personal communication, Palau representative to the Conference of the Parties, 15 March 2007.

10. Personal communication from S. Ahmed, Bangladesh Anti-Tobacco Alliance (BATA), 15 March 2007. Based on Efroymson, D., Ahmed, S., Townsend, J., et al. Hungry for tobacco: An analysis of the economic impact of tobacco on the poor in Bangladesh. Tobacco Control 2001; 10: 212-217.

11. National tobacco strategy, 2004-2009. Commonwealth of Australia, 2005. Available at: http://nla.gov.au/anbd.bib-an000041331245

12. Personal communication from T. Szilágyi, Health 21 Hungarian Foundation. Based on Szilágyi, T. Tobacco control in Hungary: Past, present, future. Health 21 Hungarian Foundation, April 2004. Available at: http://www.policy.hu/tszilagyi/ANGOL1.pdf

13. Merriman, D., Yurekli, A., & Chaloupka, F.J. How big is the worldwide cigarette smuggling problem? In P. Jha & F.J. Chaloupka (Eds.), Tobacco control in developing countries (pp. 365-392). Oxford: Oxford University Press, 2000; Sunley et al., 2000.

14. The directorate for customs and excise in Norway, 2007. Available at: http://www.toll.no ; personal communication from F.J. López Antuñano, Alianza Contra el Tabaco, A.C., Mexico, 2 April 2007.

15. National Assembly of the Republic of Armenia, website. Available at: http://www.parliament.am 16. India budget 2005-2006; Sri Lanka Ministry of Finance, 2007 – discussions with Commissioner General of Excise in

January 2007 & Sri Lanka Customs. See also http://www.customs.gov.lk/tariff/excise_2006.pdf 17. Slovakia Act no. 106, 2004 Coll. on excise duty on tobacco products.18. Australia, A new tax system (goods and services tax) act 1999; New Zealand Treasury, 2007. Available at: http://www.

treasury.govt.nz/19. The Law of Mongolia on Excise Tax (revision), 29 June 2006.20. Iceland, Tobacco control act no. 6, 2002; India – The Hindu Business Line, 2005; The Law of Mongolia on Tobacco

Control, 1 July 2005; Thailand, Health Promotion Foundation Act, 2001; Ramos, A. Study of the Tobacco industry in Uruguay. PAHO/WHO, 2004.

21. Japan Tobacco and Tobacco Institute of Japan, 2007; Madagascar, Interministry Decree no. 4892/96 MEFB/MJS of 12 October 1996.

22. National Tobacco Strategy 2004-2009, Commonwealth of Australia 2005; personal communication re: Kenya Treasury from A. Ogwell, Oral and Craniofacial Research Associates, 4 April 2007.

23. Canadian Cancer Society, Physicians for a Smoke-Free Canada. Tobacco tax rates are tracked by Canadian Cancer Society staff. Latest federal tax increases available at: http://www.fin.gc.ca/news02/02-052e.html ; http://www.fin.gc.ca/budget06/bp/bpa3ae.htm (under Tobacco Excise Levies). For a summary of various taxation strategies, see: http://www.nsra-adnf.ca/cms/file/pdf/cigarette_prices_in_Canada_January_1_2007.pdf

24. Chonlathan Visaruthvong, et al. The study of excise tax for tobacco control. Study supported by Tobacco Control Research and Knowledge Management Centre (TRC), Thailand.

25. Szilágyi, T. Tobacco control in Hungary: Past, present, future. Health 21 Hungarian Foundation, April 2004. Available at: http://www.policy.hu/tszilagyi/ANGOL1.pdf

26. Kenya Revenue Authority Regulations of 2000; New Zealand, Customs and Excise Act, 2000.27. India data collector, H. Goswami, first-hand market survey, 1-15 March 2007.28. New Zealand, Ministry of Health and data collector’s market survey, personal communication from S. Bradbrook, Te

Reo Marama of the Maori Smoke-free Coalition, 29 March 2007; Norway data collector’s market survey and media reports, personal communication from B. Rosted, Norwegian Cancer Society, 13 March 2007.

29. OANDA currency converter, Available at http://www.oanda.com/convert/classic

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Worldwide, hundreds of millions of people are involuntarily exposed to tobacco smoke in places where active smoking occurs, such as workplaces, transport facilities, other public places, and in the home.1,2,3 Scientific evidence demonstrates that exposure to tobacco smoke causes death, disease, and disability. Since the Framework Convention on Tobacco Control (FCTC) was negotiated, the research has grown even stronger, with new reports confirming that exposure to tobacco smoke causes a variety of illnesses, including premature death and disease in adults, children, and pregnant women who do not smoke.4,5,6 Scientific evidence has also shown that there is no safe level of exposure to second-hand smoke.7 The only public health policy to completely eliminate exposure to second-hand smoke and effectively protect health is a complete smoking ban in all indoor public places, workplaces, and public transport.

Various strategies that would still permit smoking indoors (such as designated smoking rooms with special ventilation) have been tried, but they have been proven to be ineffective in preventing health damage from tobacco smoke.8 The most commonly used argument to oppose smoking bans is the claim that establishing smoke-free environments causes economic damage for the hospitality industry. In fact, not a single independent and rigorous study has demonstrated such an effect.9 In most countries worldwide, the majority of the population supports establishing smoke-free environments – including most smokers.10

Provisions of the FCTC that Address Protection from Exposure to Tobacco Smoke – Article 8

The FCTC legally binds parties that have ratified the FCTC to implement effective measures to protect all their citizens from exposure to tobacco smoke in public places and workplaces. Article 8 of the FCTC states that “Parties recognize that scientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease, and disability.” Parties are required by article 8.2 to adopt and implement, in areas of existing national jurisdiction as determined by national law, “effective legislative, executive, administrative and/or other measures, providing

for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places.” At other jurisdictional levels, parties are required to actively promote adoption and implementation of these measures.

In implementing article 8, parties are to be guided by the principles outlined in article 4, which include the need to inform all persons of the health consequences of exposure to tobacco smoke and the need to take measures to protect all persons from exposure to tobacco smoke.

At its first session, the Conference of the Parties (COP) decided to commence work on the elaboration of guidelines on article 8 (FCTC/COP1-15 Elaboration of guidelines for implementation of the Convention).11 With the input of civil society, a consultative working group of parties has developed draft guidelines that will be presented to the second session of the COP. The objectives of the draft guidelines are “to clarify Parties’ obligations under Article 8 of the WHO Framework Convention, in a manner consistent with the scientific evidence regarding exposure to second-hand tobacco smoke and the best practice worldwide in the implementation of smoke free measures” and to “identify the key elements of legislation necessary to effectively protect people from exposure to tobacco smoke, as required by Article 8.”12

CHAPTER 3 PROTECTION FROM EXPOSURE TO TOBACCO SMOKEEduardo Bianco

Australia and Canada use state/provincial or municipal legislation to create smoke-free environments

AUSTRALIA• All states and territories except the Northern Territory

have passed legislation to ban smoking in pubs and clubs. Queensland and Tasmania are leading in this area as they have also banned smoking in outdoor areas serviced by staff.

CANADA • There are complete bans in Ontario, Quebec,

Manitoba, New Brunswick, Nova Scotia, Nunavut, and the Northwest territories.

• Federal legislation covers about 10 percent of workers and allows designated smoking rooms. However, many federally regulated workers have protection as a result of administrative policies that do not allow these smoking rooms.

• Municipal bylaws fill some of the gaps in these

provinces and territories which do not have protection.

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Findings from the 2007 FCA FCTC Monitor: Which Countries Are Protecting Populations from Exposure to Tobacco Smoke?

Of the 27 countries participating in the 2007 FCA FCTC Monitor, most of the data collectors report that their countries are still not effectively protecting all their population from the health risks of exposure to tobacco smoke. Data collectors from participating countries were asked first about the existing smoking ban legislation in their respective countries: Does Country X have national smoking ban legislation in indoor workplaces, public transport, and public places? As a follow-up question, data collectors were also asked to comment on the implementation of the existing policy (if any), and indicate whether health, education, and other facilities actually are smoke free (completely, partially, or not at all).13 Here is a summary of the responses.

Armenia. There is national legislation that includes a smoking ban in health care facilities, educational facilities, cultural facilities, and public transport. However, compliance is low and most facilities are not smoke free in practice.14

Australia. There is no national smoking ban legislation, but all states and territories have their own legislations that ban smoking in indoor workplaces and public places and even in some outdoor public places. Health care, government, and transport facilities are all smoke free, and most of the educational facilities are as well. All states and territories except the Northern Territory have passed legislation to ban smoking in pubs, clubs, and bars.15

Bangladesh. There is a national legislation banning smoking but it excludes some indoor workplaces, public transport, and public places. This legislation allows smoking areas but they must be made in such a way that the smoke does not enter the non-smoking zone. Health care facilities are smoke free; educational, governmental, and transport facilities are partially smoke free; however, most restaurants permit smoking.16

Canada. There is no national legislation but seven provinces and territories have completely banned smoking in indoor public places and, in some cases, protection from tobacco smoke

includes outdoor patios of bars and restaurants. In the remaining six provinces and territories, municipal bylaws fill some of the gaps in tobacco control legislation. In these jurisdictions some health care, educational, government, and transport facilities, as well as restaurants, bars, and pubs, are still not smoke free.17

Fiji. There is a national smoking ban legislation for indoor workplaces, public transport, and public places and all health care, educational, government, and public transport facilities are smoke free. There are prescribed places designated for smokers and non-smokers in restaurants but such areas are not completely separated – bars and nightclubs are not smoke free at all.18

Ghana. There is no national legislation. However, most educational facilities are smoke free and many health care facilities and public transport facilities are smoke free as well.19

Hungary. There is a national smoking ban legislation, but it allows for some exceptions. Most educational facilities are smoke free. Teachers over the age of 18 years are allowed to smoke in designated areas in primary and secondary educational facilities. In higher education facilities (e.g., universities), both teachers and students over the age of 18 years are allowed to smoke in designated areas. Some health care facilities, public transport facilities, and restaurants permit smoking as do most bars and clubs.20

Iceland. There is a national legislation and currently all educational, government, and public transport facilities are smoke free, but some health care facilities and most bars and

Expanding smoke-free environments to include outdoor areas

NEW ZEALAND• At varying levels of government (regional, local,

district council), there are increasing numbers of smoke-free policies being implemented. These create smoke-free settings outdoors in areas such as children’s parks, sports grounds, pedestrian malls, and recreational facilities.

AUSTRALIA• Legislation and local council bylaws have been

implemented to ban smoking in some outdoor areas such as playgrounds, beaches, and building exits/entrances.

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clubs are not. A complete smoking ban in all public places, including bars and restaurants, went into force 1 June 2007.21

India. The Indian Tobacco Control Act prohibits smoking in public places. However, this provision has some wide lacunae: the law defines public places ambiguously and does not address exposure to tobacco smoke in indoor private workplaces. All health care, educational, government, and public transport facilities are smoke free, but some restaurants allow smoking.22

Japan. There is a health promotion law that mandates managers “to take necessary measures to prevent passive smoking,” but most facilities are still not smoke free in practice.23

Jordan. There is a complete smoking ban in all indoor workplaces, public transport, and public places since 1974, but it is not well implemented. Only educational facilities are all smoke free.24

Kenya. A complete smoking ban in all indoor workplaces, public transport, and public places was passed in May 2006 (Legal Notice no. 37) but the tobacco industry went to court and the regulation was suspended. Still, the public has been extremely supportive of the regulations and all health care, educational, government buildings, and public transports are smoke free. Some restaurants and most bars and nightclubs still permit smoking.25

Madagascar. In spite of having a complete smoking ban in all indoor workplaces, public transport, and public places (with exceptions – smoking is permitted in certain indoor public places) since 2003, only health care and educational facilities are completely smoke free.26

Mauritius. There is a national legislation with exceptions. All educational, government, and public transport facilities are smoke free while most restaurants, bars, and clubs are not. There is a complete smoking ban in the Municipal Council of Port Louis.27

Mexico. There is a national legislation but it allows for smoking areas without a complete separation between smokers and non-smokers. Non-smoking areas in restaurants and bars cover 30 percent of the facilities.28

Mongolia. There is a national law that bans smoking in public transport and gasoline stations but allows smoking areas, without specific requirements, in all other indoor public places and workplaces.29

New Zealand. There is a complete smoking ban in all indoor workplaces, public transport, and public places since 2003. All educational, government, and transport facilities as well as restaurants and bars are smoke free. Unfortunately, some health care facilities allow for isolated smoking rooms with ventilation systems.30

Norway. Although there is a national legislation, it unfortunately allows separate smoking rooms in public and private workplaces (except for restaurants and bars). However most workplaces choose not to have a smoking room. All educational and public transport facilities, as well as restaurants and bars, are smoke free. Some government facilities and health care facilities are not.31

Kenya – Tobacco industry challenges the smoke-free legislation

In Kenya, Legal Notice no. 37 (23 May 2006) imposed a comprehensive ban on smoking in all public places and workplaces. One month later, the tobacco industry legally challenged the smoke-free legislation, and the regulation was suspended until the case is heard and completed. However, the public support for these regulations has been extremely supportive and is expected to remain so!

Uruguay – First smoke-free country in the Americas

As of 1 March 2006, Uruguay has become the first smoke-free country in the Americas region! This national smoking regulation legislation was achieved through a presidential decree (268/05, 5 September 2005). The key elements for fostering a high level of public support and compliance were: 1. Political will and commitment; 2. A smart sensitization campaign, where people were

guided to thank the smokers for not smoking in indoor places. As a result of this campaign,1.3 million acknowledgements were counted, and the strategy became known as the “thanks a million!” campaign.

3. Strong fines to business owner violators.

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Pakistan. There is a complete smoking ban in all indoor workplaces, public transport, and public places. All health care, educational, government, and public transport facilities are smoke free but some restaurants permit smoking.32

Palau. There is a national law that bans smoking in government buildings. However, all health, educational facilities, and public transports are smoke free as well. Some restaurants and most bars and nightclubs are not smoke free.33

Panama. An executive decree in 2005 banned smoking in most indoor public places and workplaces but it allows separated smoking areas with ventilation in hospitality facilities, restaurants, and bars. To date, only public transport, health facilities and educational facilities are all smoke free.34

Peru. A national legislation banned smoking in most indoor public places but allows separated smoking areas with ventilation in restaurants and bars.35

Slovakia. There is a complete smoking ban in all indoor workplaces, public transport, and public places but smoking areas have been permitted in certain indoor public places.36

Sri Lanka. The National Authority on Tobacco and Alcohol (NATA) Act no. 27 of 2006 banned smoking in all indoor workplaces, public transport, and public places, with very few exceptions. (In hotels with over 30 rooms and restaurants and bars with a seating capacity of 30 or more persons, smoking areas are permitted.)37

Thailand. The Non Smokers’ Health Protection Act gives authority to the Ministry of Public Health to regulate smoke-free areas. Currently smoking is completely banned in all public transport, schools, temples, health facilities, indoor workplaces, indoor public places, and air-conditioned restaurants except pubs and bars. However, designated smoking areas are allowed in some public places and workplaces.38

Trinidad and Tobago. There is no national legislation but through cabinet notes and other measures, all heath care, educational, and government facilities have been made smoke free.39

Uruguay. There is a complete smoking ban in all indoor workplaces, public transport, and public places since 1 March 2006. Uruguay thus became the first country in the Americas to be smoke free indoors.40

For a summary of the country situations, please refer to table 3.1 and figure 3.1.

Sanctions for Violations

All countries with either a complete or partial smoking ban include sanctions for violations in their legislation text. The types of sanctions are diverse. In some countries, monetary fines apply for any person who is smoking in a prohibited place. This is true for at least four countries participating in the 2007 FCA FCTC Monitor: Bangladesh (50 BDT or .75 USD), India (200 INR, approximately 4.92 USD), Mauritius (5,000 MUR or 163.08 USD), and Thailand (2,000 THB, which is 61.40 USD).41 In other countries, fines are applied to employers and managers who fail to implement the smoking regulations (for example, up to 4,000 NZD or 2,921.24 USD in New Zealand and up to 1,200 USD in Uruguay).42

Enforcement

Compliance High Moderate Low to none

High CanadaFijiNew ZealandNorwayUruguay

Australia Palau

Moderate HungaryMadagascarMexicoPakistanPanama

BangladeshMauritiusMongoliaSri LankaThailand

Low to none Slovakia ArmeniaIndiaJapanJordan

Table 3.1. Level of compliance and level of enforcement of the legislation on protection from exposure to tobacco smoke

Note: Ghana and Trinidad and Tobago do not currently have smoking regulation legislation in force. Data collectors from Iceland, Kenya, and Peru were unable to assess the level of enforcement and compliance.

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Finally, in some countries, fines apply both to people who smoke in a place where smoking has been banned, and to employers/managers for not implementing the legislation. This is true for both Mongolia and Mexico. In Mongolia, fines for employers/managers (up to 150,000 MNT, which is approximately 128.76 USD) are higher than those for smokers (up to 10,000 MNT, 8.58 USD).43 In Mexico, the fines are reported to be “not very high” for either employers/managers or smokers.44

Japan and Armenia are examples of countries whose smoking regulation legislation does not specify any sanctions for violations. In Japan, however, the legislation stipulates that managers are obliged to try and prevent exposure to tobacco smoke.45

Discussions at the Government Level to Strengthen Laws/Regulations

During the past year, 23 of 27 countries have had discussions among policy-makers regarding the possibility of strengthening laws/regulations that govern smoking in public places and

workplaces. In fact, in Iceland, new legislation entered into force on 1 June 2007, which banned smoking in all public places, including bars and restaurants.46 However, not all countries have had the same level of success in implementing new smoking regulation legislation. In Mexico, a complete smoking ban in indoor workplaces was rejected by the country’s Congress Health Commission. In Peru, although a complete smoking ban was approved by the same type of national commission, the Peruvian congress did not approve it.47

In several countries, such as Australia, Madagascar, Mauritius, New Zealand, Norway, Slovakia, and Thailand, the strengthening of smoking regulation legislation has been addressed at tobacco control meetings and health priority meetings with governmental participation, or in interministerial boards. The focus of the discussion tends to depend on the strength of the existing legislation. For instance, in New Zealand, the Ministry of Health is considering banning smoking in prisons, residential hospitals, and institutions that care for people with disabilities. In Australia and Norway, the possibility of banning smoking in some outdoor spaces has been discussed.48 In India, NGOs have sent recommendations to the government on banning smoking in

indoor workplaces.49 In Uruguay, where legislation has already successfully banned indoor public smoking, the parliament is also considering sanctions in the legislation for smokers. (Currently, the legislation applies fines only to employers and managers who fail to enforce legislation that regulates smoking.) The Uruguay parliament is also considering expanding the smoking regulations to prohibit smoking in some outdoor environments in health care and educational facilities as well as other public places.50

Figure 3.1. Number of data collectors indicating that the following indoor public places in their countries are totally, partially, or not at all smoke free

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Ineffective Measures

To protect a population from exposure to tobacco smoke, the legislated guarantee of a 100 percent smoke-free indoor environment is the only measure that is proven effective. However, many country legislations allow for some ineffective measures. Eleven of 27 participating countries allow for incomplete separation between smoking and non-smoking areas (Armenia, certain jurisdictions of Australia, Canada, Fiji, Hungary, Japan, Madagascar, Mexico, Pakistan, Panama, and Slovakia). Some of those are also among the 12 of 27 participating countries that allow for ventilation measures (Canada, Fiji, Hungary, Iceland, Japan, Jordan, Mexico, Pakistan, Panama, Peru, Sri Lanka, and Thailand.)

Level of Compliance and Enforcement

Data collectors from 22 countries had sufficient information to evaluate the level of implementation of the legislation (table 3.1). In several countries, the current level of compliance with the legislation on tobacco smoke is both disappointing and worrisome. Although data collectors from seven countries report that the level of compliance is high, ten report that the level of compliance with their existing smoking ban legislations is only

moderate, and five report that it is low. Similarly, the level of enforcement of the legislation is high in five countries, moderate in seven countries, and low in ten countries. In fact, having legislation for a national smoking ban does not assure full compliance with or enforcement of the legislation. Among countries with national smoking bans, only the data collectors of five countries (Canada, Fiji, New

Zealand, Norway, Uruguay) report a high level of both compliance and enforcement.

Sanctions leviedA total of 15 participating countries have levied sanctions for violating the legislation on tobacco smoke. In Australia and Canada, infringement notices and warnings have been issued and fines have been applied in some instances. In Bangladesh and Fiji, some smokers have been fined. In India, the number of fines that has been levied is very small compared to the actual number of violations. In Mexico and Mongolia, sanctions are rarely applied.

Implementation of Smoke-free Environments

When asked to describe the level of compliance in different types of public places, the following numbers of data collectors indicate that these indoor environments were completely smoke-free in their respective countries: 3 for bars, 5 for restaurants, 12 for government buildings, 13 for transport facilities, 13 for health care facilities, and 15 for educational facilities (figure 3.1). It is worrisome that in Hungary, India, and Mongolia, most of the health and educational facilities are still not smoke free.

Table 3.2. Categories of protection from exposure to tobacco smoke

* Note that this table lists examples only and cannot cover a full list of the countries because of a lack of information about some of them.

Level of protection

Description Examples among countries participating in the 2007 FCA FCTC Monitor*

Complete protection

Countries with a national smoking ban in all indoor workplaces, public transport, and public places, without exceptions, and with high levels of compliance and enforcement

New Zealand, Uruguay

Incomplete protection

Countries with smoking bans in all indoor workplaces and public places in multiple states, provinces, or cities, or with a partial national smoking ban that allows for exceptions (e.g., bars and nightclubs), and with high levels of compliance or enforcement

Australia, Canada, Fiji, Norway

Lack of effective protection for most of the population

Countries where smoking policies are lacking or are based on separated areas, ventilation systems, or other measures different from smoke-free environments

Armenia, Bangladesh, Ghana, Hungary, India, Japan, Jordan, Mauritius, Mexico, Mongolia, Pakistan, Palau, Panama

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Summary of Current Situation Considering the data collected for the 2007 FCA FCTC Monitor, and taking into account the existing scientific evidence, the existence and features of legislation, as well as compliance and enforcement level of smoke-free environments, the countries can be classified into several categories (see table 3.2).

Recommendations

To effectively protect their populations from exposure to tobacco smoke, the parties should consider the following principles:

1. The right to effective protection from involuntary exposure to tobacco smoke is implicit in the fundamental right of all persons to live in a healthy environment and to the enjoyment of the highest attainable standard of health.

2. Effective protection of health requires 100 percent smoke-free environments. For this reason, ventilation and designated smoking rooms are not acceptable measures.

3. Coverage must be comprehensive. Parties are committed to protect all persons, including vulnerable persons and those at the highest risk. Protection must include all indoor public places, all indoor workplaces, and all public transport.

4. Parties should be careful in developing legislative definitions of smoking, indoor or enclosed areas, public places, and workplaces that will help avoid loopholes and minimize enforcement problems.

5. Educating and involving opinion leaders, community and civil society organizations, and the public is essential to build strong support for effective development and implementation of successful legislation.

6. The development of a sensitization campaign will help increase public awareness on the dangers of tobacco smoke and the value of smoke-free environments as a uniquely effective solution. Such a campaign can also increase awareness of the sanctions that will be imposed for violators.

7. Appropriate enforcement responsibilities, monetary penalties, and other sanctions should be included to deter violations.

8. Parties should encourage ongoing

monitoring and evaluation to assess legislation impact, to promote compliance with the FCTC, and to build support for the most effective measures.

9. All parties should also adopt, as proposed, the draft guidelines prepared by the guideline elaboration working group for the implementation of article 8 (Document A/FCTC/COP/2/7, provisional agenda item 5.3.1), which will assist them not only to fulfill their legal duties under the FCTC, but also to follow best practices in protecting public health.

10. Ventilation and designated smoking rooms cannot be considered intermediate steps to reach smoke-free environments because these measures do not eliminate exposure to tobacco smoke.

The development of 100 percent smoke-free environments is essential. There is no other scientifically validated approach to completely protect all people from the health effects of tobacco smoke. Comprehensive legislation is effective and relatively easier to enforce to eliminate tobacco smoke exposure in public places.

Notes1. World Bank Group, 2002. Smoke-free workplaces at a glance. Available at: http://www1.worldbank.org/tobacco/

AAG%20Smoke-free%20Workplaces.pdf 2. World Health Organization, 1999. International consultation on environmental tobacco smoke and child health. Available

at: http://www.who.int/tobacco/health_impact/youth/ets/en/print.html

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3. Windsor, R.A. Smoking, cessation, and pregnancy. In J.M. Samet & S.Y. Yoon (Eds.), Women and the tobacco epidemic: Challenges for the 21st century (pp. 147-162.) Baltimore: World Health Organization and Institute for Global Tobacco Control of the Johns Hopkins School of Public Health, 2001.

4. UK Scientific Committee on Tobacco or Health (SCOTH). Second-hand smoke: Review of evidence since 1998. London: SCOTH, 2004. Available at: http://www.dh.gov.uk/assetRoot/04/10//14//75/04101475.pdf

5. US Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. Washington, DC: Department of Health and Human Services, Centers for Disease Control and Prevention, National Centre for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health, 2006. Available at: http://www.surgeongeneral.gov/library/secondhandsmoke/report/

6. California Environmental Protection Agency, Air Resources Board. Proposed identification of environmental tobacco smoke as a toxic air contaminant. June 2005. Available at: http://repositories.cdlib.org/tc/surveys/CALEPA2005

7. National Cancer Institute. Health effects of exposure to environmental tobacco smoke. Smoking and tobacco control monograph no. 10. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 1999. NIH Pub. No. 99-4645. Available at: http://cancercontrol.cancer.gov/tcrb/monographs/10/

8. Windsor, R.A. Smoking, cessation, and pregnancy. In J.M. Samet & S.Y. Yoon (Eds.), Women and the tobacco epidemic: Challenges for the 21st century (pp. 147-162.) Baltimore: World Health Organization, Institute for Global Tobacco Control, and Johns Hopkins School of Public Health, 2001; Samet J. et al. ASHRAE position document on environmental tobacco smoke. American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2005. Available at: http://www.ashrae.org/content/ASHRAE/ASHRAE/ArticleAltFormat/20058211239_347.pdf.

9. Windsor, R.A. Smoking, cessation, and pregnancy; Scollo, M., Lal, A., Hyland, A., & Glantz, S.A. Review of the quality of studies on the economic effects of smoke-free policies on the hospitality industry. Tobacco Control 2003; 12: 13-20.

10. Jones S., & Muller, T. Public attitudes to smoke-free policies in Europe. In Smoke-Free Partnership: Lifting the smokescreen. 10 reasons for a smoke-free Europe (pp. 85-103). Brussels: European Respiratory Society, 2006. Available at: http://dev.ersnet.org/uploads/Document/46/WEB_CHEMIN_1554_1173100608.pdf

11. World Health Organization. Conference of the Parties to the WHO Framework Convention on Tobacco Control. First session, list of decisions, A/FCTC/COP/1/DIV/8, 23 March 2006 Geneva. Available at: http://www.who.int/gb/fctc/PDF/cop1/FCTC_COP1_DIV8-en.pdf

12. World Health Organization. Conference of the Parties to the WHO Framework Convention on Tobacco Control. Second session, elaboration of guidelines for implementation of the convention. Decision FCTC/COP1(15). Article 8: Protection from exposure to tobacco smoke, A/FCTC/COP/2, 26 April 2007, p. 5. Available at: http://www.who.int/gb/fctc/PDF/cop2/FCTC_COP2_7-en.pdf

13. To respond to the implementation questions, many data collectors relied on discussions with tobacco control experts and stakeholders in their respective countries to form their responses.

14. HO-72-N Law on Restrictions of the Tobacco Sale, Consumption and Use, 2005. Republic of Armenia; Knowledge, attitudes, and practices on tobacco control policies in adult population in Armenia. Yerevan: Center for Health Services Research and Development, American University of Armenia, 2006; Attitudes, practices and beliefs toward worksite smoking policy among private and public administrators in Armenia. Yerevan: Center for Health Services Research, American University of Armenia, 2005.

15. Quit Victoria and VicHealth Centre for Tobacco Control. National Smokefree Legislation, October 2005. Unpublished table. Australia.

16. Smoking and tobacco products usage (control) act, 2005. Bangladesh; Government notification on tobacco control rules, Bangladesh, 30 May 2006.

17. Information compiled by the Canadian Cancer Society, the Non-Smokers’ Rights Association, and Physicians for a Smoke-Free Canada. For a recent summary of various levels of legislation, see: http://www.nsra-adnf.ca/cms/File/pdf/prov_smokefree_leg_reg_policies_January_2007.pdf

18. Tobacco control Act 1998 and Occupational Health and Safety Regulations. Fiji.19. Personal communication from E. Wellington, Ghana Health Service, 4 April 2007.20. Act 42 of 1999 on the protection of non-smokers and the regulation of tobacco sales, marketing and use, Hungary.21. Tobacco control act 6/2002. Iceland.22. Tobacco Control Act no. 83/2006. India; The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and

Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003. India.23. Health Promotion Law (Art 25), 1 April 2003. Japan.24. Public Health Law no. 21, 1971 and Health Protection Act no. 64, 1974. Jordan.25. Legal notice no. 44, Legislative Supplement no. 20. Public Health (Tobacco Products Control) Rules, 2006. Kenya.26. Inter Ministry decree 18 171/2003. Madagascar.27. Public Health Act (Restrictions on Tobacco Products) Regulations, 1999. Mauritius.28. Rules of Tobacco Consumption, published in the Federal Official Diary, 31 May, 2000. Mexico.29. The Law of Mongolia on Tobacco Control, 2005.30. Smoke-free Environments Act, 1990 and Amendment Act, 2003. New Zealand.31. Act no. 14, Protection against Tobacco-related Health Damage, 9 March 1973. Smoke-free Public Places: The

Directorate for Health and Social Affairs in Norway. History available at: http://www.shdir.no32. The Prohibition of Smoking in Enclosed Places and Protection of Non-smokers Health Ordinance, 2002. Pakistan.33. Republic of Palau Public Law 3-62, 1991.34. Executive decree 17, 11 March 2005. Panama.35. Law no. 28705 for prevention and control of smoking risks, 2006. Peru.36. Act no. 465/2005 on Protection of Non-Smokers. Slovakia.

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37. National Authority on Tobacco and Alcohol, Act no. 27 of 2006, section 39. Sri Lanka.38. Announcement no. 17, Ministry of Public Health, 2006. Thailand.39. Personal communication from C. Alexis-Thomas, Coalition for Tobacco-Free Trinidad and Tobago, 26 March 2007.40. Presidential Decree 268/05, 5 September 2005. Uruguay.41. Personal observation by Bangladesh representative during meetings where draft law was discussed – December

2005 through May 2006; Indian Tobacco Control Act 2003; Occupational Safety, Health and Welfare act, Duties of employees, 1988. Mauritius; Announcement no. 17, Ministry of Public Health, 2006. Thailand.

42. The New Zealand Smoke-free Environments Act, 1990; currency converted to US dollars 26 May 2007; Presidential Decree 268/05, 5 September 2005. Uruguay.

43. The Law of Mongolia on Tobacco Control, 1 July 2005, articles 9 and 13.44. Personal communication from F.J. López Antuñano. Alianza Contra el Tabaco, A.C., Mexico, 2 April 2007.45. Health Promotion Law, article 25. Japan.46. Tobacco Control Act no. 83/2006. Iceland.47. Personal communication from F.J. López Antuñano. Alianza Contra el Tabaco, A.C., Mexico, 2 April 2007; personal

communication from C.F. Alburqueque. Comisión Nacional Permanente de Lucha Antitabaquica (COLAT), Peru, 4 April 2007.

48. After the smoke has cleared: Evaluation of the impact of a new smokefree law – Outstanding issues and recommendations for policy and research. Wellington, NZ: Ministry of Health, January 2007. Available at: http://www.moh.govt.nz; Personal communication from K. Lindorff, Victoria Health Centre for Tobacco Control, Australia, 26 March 2007. The Norwegian Olympic Committee and Confederation of Sports stated on their website on 8 June 2006 that they want smoke-free sports arenas. The president (confederation of sports), Karl-Arne Johannessen, spoke on the same issue in one of the country’s largest newspapers, 6 June 2006. Available at: http://oslopuls.no/nyheter/article1341419.ece

49. Personal communication, M. Arora, Health-Related Information Dissemination amongst Youth (HRIDAY), India, 26 March 2007.

50. Uruguay parliamentary citation no. 178, 3 May 2007, Deputy Chamber Agenda, File 934/006. Available at: http://www.parlamento.gub.uy/palacio3/index1024.htm

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From the point of view of both governments and tobacco companies, the design of a tobacco product’s package is the most important form of communication. Because a smoker may reach for a cigarette package 20 or more times a day, package messages work 24 hours a day, 7 days a week, and reach all consumers, as well as many others (e.g., friends, family, co-workers). Considering that governments design and select the warnings, and the tobacco industry pays the cost of printing, package warning messages are a highly cost effective system of public health education that benefits tobacco control. When properly implemented, package warnings increase awareness of the health effects, increase concern about the health effects, and decrease consumption.

Package warnings and labelling are being improved dramatically worldwide, principally as a result of the Framework Convention on Tobacco Control. At the time FCTC negotiations began in October 2000, only three countries in the world (Canada,1 Poland,2 and Thailand3) are known to have had warnings covering at least 30 percent of the front and back of cigarette packages – the eventual FCTC minimum standard. Only Canada had required picture-

based warnings and had warnings covering 50 percent of the packages (which became the eventual FCTC-recommended standard), and even in Canada these requirements were new and had not yet appeared on packages.4 No country had yet specifically banned the misleading cigarette descriptors “light” and “mild”– Brazil became the first to do so in March 2001, followed by adoption of the European Community Directive in June 2001.5

Provisions of the FCTC that Address Package Warnings and Labelling of Tobacco Products

Pursuant to article 11.1b of the FCTC, parties must require a rotated series of health warnings (or other appropriate messages) that should be at least 50 percent – and must be no less than 30 percent – of the package front and back, with optional use of pictures or pictograms. This obligation extends to all packaging seen by consumers, such as cartons. A rotated series of messages may include non-health messages, such as “Quit smoking, save money.” Messages are to be approved by the competent national authority. Article 11.3 provides that messages are to appear in the principal language(s) of the country.

CHAPTER 4 PACKAGE WARNINGS AND LABELLINGRob Cunningham

Figure 4.1 Legislated Requirements for Cigarette Package Health Warnings

8

5

8

17

15

17

17

24

0 5 10 15 20 25

Requiring use of pictures

Size: 50% or more of package front

Size: 50% or more (average) of package front/back

Size: 30% or more (average) of package front/back

Requiring warnings in full colour or in black & white

Requiring warning message onpackage front

Rotated warnings

In principal language or languages of country

Req

uir

emen

t

Number of Countries

Figure 4.1. Legislated requirements for cigarette package health warnings

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Table 4.1. Overview of national package warning requirements

Legend: b & w = black and white; c = colour

Legislated Warnings

Number of Rotated Messages

Size: Average of front and back

Size: Front

Size: Back

Pictures Colours specified

Ban “light” and “mild”

Armenia √ 1 front; 4 back

30% 30% 30% √

Australia* √ 2 sets of 7, changed annually

60% 30% 90% √ c √

Bangladesh √ 1 of 6, changed every 6 months

30% 30% 30% b & w

Canada* √ 16 50% 50% 50% √ c √

Fiji √ 3 10% 0% 20%

Ghana √ 1 0% 0% 0%

Hungary √ 2 front; 14 back

35% 30% 40% b & w √

Iceland √ 2 front; 14 back

48% 43% 53% b & w √

India* √ 2 50% 50% 50% √ c √

Japan √ 8 30% 30% 30%

Jordan √ 1 30% 30% 30% √ c, b & w

Kenya* √ 1 0% 0% 0%

Madagascar* √ 1 50% 50% 50%

Mauritius √ 1 0% 0% 0%

Mexico* √ 3 25% 0% 50%

Mongolia* √ 1 20% 20% 20% b & w

New Zealand*

√ 2 sets of 7, changed annually

60% 30% 90% √ c

Norway √ 2 front; 14 back

48% 43% 53% b & w √

Pakistan √ 1 30% 30% 30%

Panama √ 3 50% 0% 100% √ c

Peru* √ 10 proposed

25% 0% 50% √

Slovakia √ 2 front; 14 back

35% 30% 40% b & w √

Sri Lanka √ 1 0% 0% 0%

Thailand √ 9 50% 50% 50% √ c √

Uruguay √ 4 front; 4 back

50% 50% 50% √ c √

Palau

Trinidad & Tobago

*Notes

Australia The ban on “light” and “mild” descriptors arises through a court-enforceable agreement between the Australian Competition and Consumer Commission and the three major tobacco companies.

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Notes (continued)

Canada The ban on “light” and “mild” descriptors arises through a court-enforceable agreement between the federal Competition Bureau and the three major tobacco companies, and is being implemented during 2007.

India The information in this chapter refers to a new warning system not yet in force. The warning is to appear in the languages used on the package, to a maximum of two languages. Where the language that appears on the package is foreign, the warning is to appear in English.

Kenya A national rule requiring 50% text warnings on the front and back has not come into force due to a court proceeding.

Madagascar Regulations require a bilingual health warning to appear on 50% of one side, and a bilingual “For sale in Madagascar” to appear on 50% of the other side.

Mexico The warnings actually appearing on packages cover 50% of one side (companies choose the back side) pursuant to a voluntary agreement. However, existing legislation requires warnings on only 25% of one side.

Mongolia There are two laws. One law (that is obeyed) says that warnings should be at least 20% of the front and back. The other law (that is not enforced) requires that warnings must be at least “one third of the external surface of all sides of tobacco pack.” The law requires “clear” letters on a white background inside a black square frame; in practice the letters appear in black, although it is possible for another colour to be used. According to a 2001 standard, each cigarette pack has the same messages, with one message on the front and a different message on the back. A 1994 health ministry list contained six messages, some of which appear on packages, but this list apparently is not considered mandatory.

New Zealand The information in this chapter refers to new warnings and regulations to come into force in February 2008

Peru Legislation authorizes picture warnings that are in the process of being finalized. The 50% size is included in legislation but not yet implemented.

Thailand An exemption from the “light” and “mild” ban is made for the trademark “Mild Seven.”

Article 11.1a requires parties to ensure that “tobacco product packaging and labelling do not promote a tobacco product by any means that are false, misleading, deceptive or likely to create an erroneous impression about its characteristics, health effects, hazards or emissions, including any term, descriptor, trademark, figurative or any other sign that directly or indirectly creates the false impression that a particular tobacco product is less harmful than other tobacco products. These may include terms such as ‘low tar,’ ‘light,’ ‘ultra-light,’ or ‘mild.’” Article 11.2 is a provision regarding relevant information appearing elsewhere on the package about constituents and emissions, to the extent defined by national authorities. The obligations in article 11 apply within a country to both imported and domestically manufactured tobacco products (including cigarettes and other types of tobacco products). The article 11 obligations must be implemented within three years of the FCTC coming into force for that party.

Findings from the 2007 FCA FCTC Monitor: Which Countries Have Legislated Requirements for Tobacco Package Health Warnings and Labelling?

Of the 27 countries participating in the 2007 FCA FCTC Monitor, data collectors from 25 countries report that there is a legislated requirement for package health warnings. The two countries where there is not yet any legislative requirement for package warnings are Palau and Trinidad and Tobago. This chapter, which is based on information provided by data collectors,6 largely focuses on the 25 countries with legislated requirements for package health warnings. Figure 4.1 summarizes some results, while table 4.1 provides more detail.

Compliance

Overall, there is very good compliance with national laws regarding package warnings. An exception is when there is contraband, which was reported in several countries. In Mauritius, many brands (which are otherwise legally imported) do not have a health warning text that adequately complies with legislative requirements.7

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Approval by Competent National Authority

In all 25 countries with legislated warnings, the warnings were approved by a national authority. And, with the exception of Japan, it appears that the health warnings were approved by a competent national health authority in each country (although in some cases responsibility for the warnings was joint with one or more other departments).8 In Japan, the warnings are approved by the Ministry of Finance, which is the controlling owner of the tobacco manufacturer Japan Tobacco.9

Warnings in Principal Language or Languages

Data collectors from all countries but one reported that the warnings are to be in the principal language or languages of the country. The sole exception was Mauritius, where the warning is required to be printed in English even though virtually all of the population speaks Creole, about 80 percent speaks French, and only a minority understand English (and 20 percent of the population is illiterate).10

Several countries require bilingual warnings (Canada, Kenya, Madagascar, New Zealand, Pakistan and, depending on languages on the package, India) or trilingual warnings (Fiji and Sri Lanka). Canada requires one language on the front and the other language on the back.11 Madagascar has messages in two languages on both the front and back, while New Zealand has messages in English on the front, and English and Te Reo Maori on the back.12 In Fiji, messages in Fijian and Hindustani are on the front, while an English message is on the back.13

Use of Pictures

Picture-based health warnings are more effective than text-only warnings.14 Pictures are especially important for low-literacy populations. Eight of the participating countries require

picture warnings: Australia, Canada, India, Jordan,15 New Zealand, Panama, Thailand, and Uruguay. Figure 4.2 provides examples of some of the image-based warnings in use. Picture warnings are being considered in Iceland, Mongolia, Norway, and Peru. If Iceland and Norway do establish requirements for pictures in the future, these countries will choose from among the European Commission library of 42 picture warnings. In Peru, a proposed set of 10 picture-based messages has been prepared.16

Size of Warnings

The effectiveness of health warnings increases with size.17 Further, a larger space allows for the inclusion of more information, as text and/or pictures. Table 4.2 provides the size of warnings required in each country (with the rank order based on the average of the package front and back).

Required average size of warning

Country and specific requirements

60% • Australia (30% front, 90% back)• New Zealand (30% front, 90% back)

50% • Canada (50% front, 50% back)• India (50% front, 50% back)• Madagascar (50% front, 50% back)• Thailand (50% front, 50% back)• Uruguay (50% front, 50% back)• Panama (100% of one side)

48% • Norway (43% front, 53% back, including border)18

• Iceland (43% front, 53% back, including border)19

35% • Hungary (30% front, 40% back)20

• Slovakia (30% front, 40% back)21

30% • Armenia (30% front, 30% back)• Bangladesh (30% front, 30% back)• Japan (30% front, 30% back)• Jordan (30% front, 30% back)• Pakistan (30% front, 30% back)

25% • Mexico (50% of one side)22

• Peru (50% of one side)

20% • Mongolia (20% front, 20% back)

10% • Fiji (20% of one side)

0% • Kenya (warning may appear on side)• Mauritius (warning may appear on side)• Sri Lanka (warning appears on side)• Ghana (warning may appear on side)• Palau (no legislation reported)• Trinidad and Tobago (no legislation reported)

Table 4.2. Country rankings for cigarette package warning size

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Australia – front Australia – back Thailand – fronta Uruguay Uruguay

New Zealand – frontb New Zealand – backb New Zealand – frontb Jordan – front Jordan – backc

Canada – front Canada – front Canada – front Panama – back Panama – back

Iceland – front Iceland – back Norway – front Japan Japan

Figure 4.2. Images of package warnings

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Mexico – back Bangladesh – front Mongolia – front Madagascar – one side Madagascar – other sided

Mauritius – fronte Mauritius – fronte India frontf

Thailand – Full set of new round of 9 messagesa

India – frontf Sri Lanka - side

Canada – various packages including cartong

Notes(a) Thailand: The first image shown is from the first round of package warnings. The full set of the second round of picture-warnings is included; three of the nine images in the second round are repeated from the first. (b) New Zealand: A mock up of a new picture warning is shown (30% front, 90% back), to be in place by February 2008, as well as an example of a package front (30% of the front) before new regulations take effect. (c) Jordan was the first Arabic country to require picture warnings. (d) Madagascar: One side of the package in Madagascar is the message “For sale in Madagascar” (e) Mauritius: Two examples from Mauritius are shown. No warning is required on the front. If a warning appears on the front, it may be because the package was also intended for another market. (f) India: warnings are not required to appear on the package front under old regulations. (g) Canada: some examples of warnings on cartons, tubs of roll-your-own tobacco, and other package formats.

Figure 4.2. (continued) Images of package warnings

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Of the 25 participating countries with health warning legislation, eight (Peru, Mongolia, Mexico, Fiji, Ghana, Kenya, Mauritius, and Sri Lanka) do not yet have warnings large enough to meet the FCTC’s 30 percent minimum-coverage standard, even though the implementation deadline for these countries is pending – 27 February 2008. Some 16 of 25 countries with legislation do not yet have warnings to meet the recommended 50 percent FCTC standard. The eight countries that meet or exceed this 50 percent standard are: Australia, Canada, India, Madagascar, New Zealand, Panama, Thailand, and Uruguay.

From a communications perspective, the package front is far more important than the package back. Five countries require package warnings with a minimum size of 50 percent on the front: Canada, Madagascar,23 India, Thailand, and Uruguay.

Placement of Warnings on the Principal Display Surfaces

At least five countries specify that warnings should appear at the top of the package front/back: Australia, Canada, New Zealand, Pakistan, and Thailand. If no placement at the top is specifically required, manufacturers normally place the warning at the bottom of the display surface instead of at the top.

Package Inserts/Interior Messages

In two countries, interior messages appear in addition to messages on the package

exterior. Canada requires one of sixteen rotated messages to appear on an insert or on the inside “slide” portion of “slide and shell” packages.24 Package inserts/onserts also appear in Mexico.

Warning Colour

All of the eight countries that require picture warnings require such pictures to be in colour (Australia, Canada, India, Jordan, New Zealand, Panama, Thailand, and Uruguay). At least five countries require text warnings to be in black and white: Bangladesh, Hungary, Iceland, Norway, and Slovakia.25 Fiji requires the text to be black, without specifying the background colour.26 Mongolia’s requirement is vague, asking for “clear” text on a white background, but in practice the warnings are normally printed in black letters on a white background.27 Aside from this atypical case of Mongolia, experience worldwide shows that unless the law specifies the exact colour to be printed, tobacco companies will choose colour combinations that hide rather than highlight the message. Some examples of industry practice are cited later in this chapter.

Quitline Telephone Number/Web Address

At least two participating countries (Australia and New Zealand) require a quitline telephone number to appear on packages. In Canada, a web address is found on the insert/interior message and in Mexico, a telephone number appears on package inserts.

Figure 4.3. Number of rotated warnings on cigarette packages by country

Number of Rotated Warnings Required to Appear Simultaneously

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Rotation of Warnings

Rotation of warnings may occur in one of two different ways: (1) having different messages appearing simultaneously on different packages; (2) requiring in advance that warnings on packages change after a specified period of time. Having different messages appear simultaneously on different packages is more common, but the number of rotated messages appearing simultaneously varies considerably: Canada (16), Peru (10, proposed), Thailand (9), Japan (8), Australia (7), New Zealand (7), Mexico (3), Panama (3), Fiji (3), India (2). For Canada, in addition to 16 rotated exterior picture-based messages, there are also 16 rotated interior text-only messages (the interior messages appear either on an insert or on the inside “slide” portion of “slide and shell” packages).

Hungary, Iceland, Norway, and Slovakia each have two rotated messages on the front and 14 rotated messages on the back of packages, in conformity with the EC Directive. In Uruguay, four rotated messages appear on the front and four different rotated messages appear on the back (the total number of messages is eight).28 Armenia requires one standard message on the package front, and a rotated series of four messages on the back.29

Three countries require in advance that warnings on packages change after a fixed period of time. Australia and New Zealand each have two sets of seven warnings (total of 14 warnings per country), with each set of seven replacing the other every twelve months.30 In Bangladesh, one of six warnings appears on packages at a time and is changed every six months; thus after three years each of the six warnings will have appeared for six months.31

Ghana, Jordan, Kenya, Madagascar, Mauritius, Mongolia, Pakistan, and Sri Lanka require a single warning with no rotation of any kind, and are thus not yet in compliance with the FCTC article 11 in this respect.

Sleeves

In Australia, Canada, and Panama – all countries

that requires picture warnings – the sale of sleeves (i.e., pack covers that are able to cover the warnings) also occurs. Data collectors from Australia and Panama, where picture warnings were more recently implemented, report that sleeves are currently sold. In Canada, such sleeves were commonly available in 2001, when the new picture warnings were introduced, but they are not common today. Data collectors from Australia and Canada also report the sale of cigarette tins and containers (sold empty) depicting no warnings at all.32 In India, legislation specifically prohibits the sale of sleeves.33

Emissions

The following countries appear to require the package to depict tar and nicotine yields (and

sometimes also carbon monoxide yields) using the ISO34 machine test method: Armenia, Fiji, Hungary, Iceland, India, Japan, Jordan, Mexico, Mongolia, Panama, Peru, Slovakia, and Sri Lanka. Canada requires yield numbers for six emissions (tar, nicotine, carbon monoxide, formaldehyde, hydrogen cyanide, and benzene) to appear on the side of the package, using both the ISO method, and a more intensive machine test method.35

Unfortunately, it is now recognized that the ISO method is flawed and does not represent the intake of substances by smokers. Because the ISO method is a machine test, it cannot collect data that accurately represents human smoking behaviour, and cannot account for smoker compensation (such as covering ventilation holes in the filter with fingers or lips). The WHO Scientific Advisory Committee on Tobacco Product Regulation has recommended that “tar, nicotine and CO numerical ratings based upon current ISO/FTC methods and presented on cigarette packages and in advertising as single numerical values are misleading and should not be displayed.”36

In Australia and New Zealand, changes to national law have removed a previously existing requirement to depict on the side of the package ISO yield numbers for tar, nicotine, and carbon monoxide. The previous approach has

• Smoking exposes you to more than 40 harmful chemicals.

• These chemicals damage blood vessels, body cells and the immune system.

• QUIT NOW to reduce your risk of chronic illness or premature death.

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been replaced with qualitative text that does not refer to yield numbers. On page 31 is the side panel used in Australia.37 In Thailand, one side panel refers to three carcinogens in smoke (formaldehyde, tar, nitrosamines), while the other side panel refers to two toxic agents in smoke (hydrogen cyanide, carbon monoxide). The ISO yield numbers are not required.38 In all these countries, the information regarding emissions normally, if not always, appears on the side of the package.

Misleading Descriptors

The cigarette descriptors “light” and “mild” are specifically banned in 11 countries: Armenia, Australia,39 Canada,40 Hungary,41 Iceland, India, Norway, Peru, Slovakia, Thailand,42 and Uruguay. However, tobacco companies are getting around these bans by using differing package colours, or using a colour or a number as part of the brand name. Here are reports from Slovakia and Uruguay:

Slovakia. The words mild, light, or low tar are not used, but colours are used in cigarette brand names.43

Uruguay. The tobacco industry doesn’t use the misleading terms banned: light, mild, ultra-light, but has maintained misleading or deceptive features through colours (e.g., ultra-silver, blue) or numbers.44

Several countries have sought to broaden the wording of their legislation to help curtail tobacco industry behaviour. Legislative text from Bangladesh, India, and Slovakia is used as an example here. However, practical enforcement of the provisions from these three countries remains a problem.

Bangladesh. “No person or institution shall use any sign, word, colour or picture on the printed packet or carton of tobacco products which is inconsistent with the warning

mentioned in the Act or contrary to the contents thereof.”45

India. “This prohibition includes, but is not limited to … similar words or descriptors; any graphics associated with, or likely or intended to be associated with, such words or descriptors; and any product package design characteristics, associated with, or likely or intended to be associated with, such descriptors.”46

Slovakia. “the packaging of tobacco products must not use any text, denominations, marks, and figurative signs that create an impression that some particular tobacco product is less harmful that others.”47

Data collectors from several countries, including Armenia and Mexico, have reported that companies are registering as trademarks their brands with descriptors such as “lights” as part of the brand name. The companies seemingly want to make it more difficult to eliminate these misleading terms from tobacco packages. Such trademark registration, however, should in no way discourage government action.

Examples of Difficulties Experienced

Warnings with poor visibility

Kenya. The health warning on current packaging is small and not effective at all. The initial legal notice did not make provisions for clarity and size and thus is a small and hidden message without much impact.48

Mauritius. The warning is printed in the smallest font, occupying one side of the packet, and is camouflaged in gold ink on a yellow background or silver ink on a white background. This warning is in fact unnoticeable, and unknown even to most long-time smokers! Graphic warnings would be ideal for a country like Mauritius.49

Example of approach leading to unexpectedly quick success

Uruguay. In 2005, the ministry of health asked its lawyer what needed to be done to have 50 percent warning labels in cigarette packaging. The answer: nothing – you can have it tomorrow using a 1998 decree related to tobacco control. Lessons learned: we need to check our legislation and ask for advice from the experts. Frequently, old legislation will authorize what needs to be done to implement the FCTC.55

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Industry tactics using packaging

Australia. Cigarette manufacturers breached the regulations for some packages by printing health warnings on adhesive labels that were easy to remove from the cigarette tins to which they had been affixed.50 Further, in 2006, court action was taken when British American Tobacco Australia launched a special edition range of Dunhill packs that could be split down a perforated edge into two smaller packs, neither of which complied with the legislation after separation.51

India. Some of the new packaging for cigarettes is unlike the traditional simple packaging. Now packaging is more attractive and on-package advertising has become innovative. For a new brand “I.gen,” marketed by the Godfrey Philips India Ltd., the Philip Morris subsidiary, the package depicts phrases such as “Basically Awesome Cigarettes” “by Invitation Only” and “Dlite 4 senses 24/7.” Figure 4.2 shows an image of a package of Four Square cigarettes (picture-based package warnings have not yet appeared on packages in India).

Tobacco products sold without packages

Mongolia. With high rates of rural and urban poverty in Mongolia, the enforcement of prohibition to sell cigarettes individually52 and unpacked loose tobacco remains a major challenge.53 (Sri Lanka also has a high proportion of cigarettes sold as singles.)54

Recommendations

Package warnings

1. Warnings should be larger than the 50 percent recommended size in the FCTC, and should cover 80 percent or more of the front and back of the package.

2. Warnings should include full-colour pictures instead of using only text.

3. After a fixed period of time, to keep warnings fresh, there should be a pre-planned change to warnings to have a new series of messages. In Australia and New Zealand, regulations require a change every 12 months.

4. Warnings should be placed on both the front and back of the package, not just on one principal display surface (such as 100 percent of either front or back).

5. Tobacco companies should not be allowed to choose the principal display surface on which to place the warning. If the warning is placed on the back, it will be less visible to consumers and at retail.

6. When placing warnings on the front and back surfaces of the package, it is normally better to require warnings at the top rather than the bottom of each surface.

7. Warnings should be required for all six sides of cigarette cartons.

8. Regulations should be as precise as possible to ensure that the messages appear exactly as the government intends, and that tobacco companies do not weaken the appearance of the message (for example, manufacturers will use very small lettering unless a minimum font size is specified; manufacturers will also use colours with poor visibility unless colours are specified).

9. Inserts or onserts, or other interior messages, should be required in addition to exterior messages, as is seen in Canada and Mexico.

10. A health warning or other message could be considered for requirement directly on the filter portion of cigarettes. While this would be beneficial in all countries, it would have extra impact for those countries where there is a high proportion of sales of individual cigarettes that are not in a package.

11. In general, national laws should be structured so that changes to warning requirements can be made by regulation/decree, without having to go back to parliament each time. Changes by parliament normally take far longer.

12. Where appropriate, a toll-free quitline telephone number and/or website address should be included as part of a package-warning system.

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Notes1. Tobacco Products Control Regulations, amendment, SOR/93-389, amending Tobacco Products Control Regulations,

SOR/89-21. Canada.2. Simpson, D. Poland’s world-leading health warnings. Tobacco Control 1998; 7: 227.3. Chitanondh, H. Thailand: Country report on labelling and packaging. Geneva: World Health Organization, 2003.4. Tobacco Products Information Regulations, SOR/2000-272. Canada. Available at: http://www.canlii.org/ca/regu/

sor2000-2725. Resolution RDC no. 46, 28 March 2001. Brazil. This was followed by the European Community Directive 2001/37/EC

adopted 5 June 2001. It would take more time before the EC Directive was implemented at the country level.6. Data collectors generally provided detailed information with respect to packages of cigarettes, rather than other

tobacco products. As a result, the information in this chapter is limited to package warnings/labelling for cigarettes. 7. In Mauritius, the Public Health (Restrictions on Tobacco Products) Regulations 1999 requires “a warning to the effect

that smoking causes cancer, heart disease, and bronchitis.’” Although this specific phrase was previously printed on packages from a BAT factory in Mauritius, now that the factory has closed, imported cigarettes may have more general phrasing such as “tobacco seriously damages health.”

Toxic emissions

13. ISO yield numbers should not be displayed on cigarette packages, and national regulations that currently require their display should be amended to remove such a requirement.

14. To the extent that national authorities are going to define constituents/emissions that should appear on the side panel or elsewhere on the package, then a qualitative text approach without ISO machine-yield numbers should be used (as Australia and New Zealand have now done).

Deceptive labelling

15. Not only should the descriptors “light,” “ultra light,” “mild,” and “low-tar” be banned, but so should similar terms (in any language), and so should all deceptive packaging.

Plain packaging

16. Plain packaging (or “generic packaging”) should be required for all tobacco products.

Providing assistance to parties

17. The Conference of the Parties (COP) should,

at its second session (COP-2), initiate a process to develop guidelines to assist parties in implementing article 11, with the objective that guidelines would be adopted at the third session of COP (COP-3).

The WHO Tobacco Free Initiative, the FCTC Secretariat, or another appropriate entity should ensure that:

18. A full set of images of all package warnings in all countries is placed on the Internet.

19. National tobacco laws of all countries are placed on the Internet, and translated into other WHO official languages where practicable (Arabic, Chinese, English, French, Russian, Spanish).

20. A legislative bureau is established to assist countries in the drafting and review of tobacco control laws, including the preparation of package warning/labelling requirements.

21. A special office is given responsibility to facilitate, as agent, the licensing of pictures used in package warnings from the originating country to other countries worldwide that would like to use the picture.

Websites with more information

www.graphicwarnings.org (English)www.nuigrav.org (French)http://www.smoke-free.ca/warnings/default.htm – Physicians for a Smoke-free Canadahttp://www.paho.org/English/AD/SDE/RA/Tob_pack_index.htm – Pan-American Health Organization (PAHO)http://www.europeancancerleagues.org/ – European Cancer Leagues

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8. In the case of Hungary and Slovakia (members of the EC), as well as Norway and Iceland (which follow the EC Directive), the content of the messages is specified in the EC Directive 2001/37/EC, which in turn has been implemented by these four countries into national law.

9. Tobacco Business Law, 1984. Japan.10. Personal communication from V. LeClezio, ViSa, 6 May 2007, Mauritius.11. Tobacco Products Information Regulations, SOR/2000-272. Canada.12. Arrête Interministériel fixant la réglementation en matière d’industrialisation, d’importation, de commercialisation

et de consommation des produits du tabac à Madagascar, 22 October 2003. Madagascar; Smoke-free Environments Regulations 2007, 2007/39. New Zealand.

13. Tobacco Control Act 1998, Act no. 47 of 1998. Fiji.14. Hammond, D., Fong, G.T., Borland, R., Cummings, K.M., McNeill, A., & Driezen, P. Text and graphic warnings on cigarette

packages: Findings from the international tobacco control four-country study. American Journal of Preventive Medicine 2007; 32(3): 202-209; Hammond, D., Fong, G.T., McDonald, P.W., Cameron, R., & Brown, K.S. Impact of the graphic Canadian warning labels on adult smoking behaviour. Tobacco Control 2003; 12(4): 391-395; Hammond, D., Fong, G.T., McDonald, P.W., Brown, S., & Cameron, R. Graphic Canadian cigarette warning labels and adverse outcomes: Evidence from Canadian smokers. American Journal of Public Health 2004; 94(8): 1442-1445; Environics Research Group Ltd. Evaluation of new warnings on cigarette packages. Prepared for Canadian Cancer Society, 2001. Available at: http://www.cancer.ca/ccs/internet/standard/0,3182,3172_334419_436437_langId-en,00.html ; Canadian Cancer Society. Controlling the tobacco epidemic: Selected evidence in support of banning all tobacco advertising and promotion, and requiring large, picture-based health warnings on tobacco packages. Ottawa: Canadian Cancer Society, International Union Against Cancer, 2001. Available at: http://www.hc-sc.gc.ca/hl-vs/tobac-tabac/research-recherche/por-rop/label-etiquet/index_e.htm Research prepared for Canadian Health Department. Available at: http://www.hc-sc.gc.ca/hecs-sesc/tobacco/research/archive/index.html; Research prepared for Australian Health Department. Available at: http://www. health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strateg-drugs-tobacco-warnings.htm ; Research prepared for New Zealand Health Department, Available at: http://www.ndp.govt.nz/tobacco/smokefreeenvironments/reviewofregulations.html

15. In Jordan, a text message appears on the front, and a picture appears on the back. Personal communication from Z. Alawneh, Land and Human to Advocate Progress (LHAP), 4 April 2007.

16. Personal communication from C.F. Alburqueque, Comisión Nacional Permanente de Lucha Antitabaquica (COLAT), Peru, 4 April 2007.

17. See Note 14.18. In Norway and Iceland, in compliance with the EC directive 2001/37/EC, the black border is to be in addition to the

30% size on the front and 40% size on the back. This works out to about 43% on the front and 53% on the back. The 43% and 53% sizes may vary by 1 to 2% depending on the package size and format.

19. Ibid.20. In Hungary and Slovakia, the black border appears within the 30% space on the front, and 40% on the back. This

is not compliant with the EC Directive 2001/37/EC. See the European Commission. First report on the application of the Tobacco Products Directive. Brussels: Commission of the European Communities, 27 July 2005, p. 5. Available at: http://ec.europa.eu/health/ph_determinants/life_style/Tobacco/Documents/com_2005_339_en.pdf

21. Ibid.22. See note accompanying table 4.1.23. In Madagascar, messages are required to cover 50% of the front and back, with a health warning on one side and a

“For sale in Madagascar” message on the other. Personal communication from J. Andrianomenjanaharinirina, Office National de Lutte Antitabac (OFNALAT), 12 May 2007; Arrête Interministériel fixant la réglementation en matière d’industrialisation, d’importation, de commercialisation et de consummation des produits du tabac à Madagascar, 22 October 2003

24. Tobacco Products Information Regulations, S.O.R./2000-272. Canada. Available at: http://www.canlii.org/ca/regu/sor2000-272

25. The EC Directive requires black text on a white background. Hungary and Slovakia are EC members, while Norway and Iceland comply with EC tobacco package labelling requirements.

26. Tobacco Control Regulations, 2000. Fiji.27. Personal communication from M. Jargal, on behalf of Adventist Development and Relief Agency (ADRA) Mongolia, and

Children, Youth, and Family Association, 7 May 2007.28. Presidency of Uruguay web page. Presidential decree 171/05, 31 May 2005. Retrieved 27 March 2007 from: http://

www.presidencia.gub.uy/_web/decretos/2005/05/05_2005.htm29. Personal communication from N. Movsisyan, American University of Armenia, 13 May 2007.30. Trade Practices (Consumer Product Information Standards) Tobacco Regulations. Statutory Rules 2004, no. 284.

Australia; Smoke-free Environments Regulations, 2007/39. New Zealand.31. Smoking and Tobacco Products Usage (Control) Act, 2005 and Smoking and Tobacco Products Usage (Control) Rules,

2006. Bangladesh.32. Personal communication from K. Lindorff, VicHealth Centre for Tobacco Control, Australia, 26 March 2007, based on

information from media coverage; personal communication from M. DeRosenroll, Canadian Cancer Society, 23 March 2007; personal communication from R. Roa, Coalición Panameña Contra el Tabaquismo (COPACET), 21 March 2007.

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33. In India, the Cigarettes and other Tobacco Products (Packaging and Labelling) Rules, G.S.R. 402(E) 2006 state: “No person shall sell or supply any product, device, or other thing that is intended to be used, or that can be used, to cover, obscure, mask, alter, or otherwise detract from the display of specified health warning on the tobacco product package. This includes prohibition to design the product package or parts of the package, or accessories thereto, with any cover that may obscure the prescribed messages.” Section 7(1)

34. ISO stands for the International Organization for Standardization.35. Tobacco Products Information Regulations. Canadian Legal Information Institute. Retrieved 23 March 2007 from:

http://www.canlii.org/ca/regu/sor2000-272 36. WHO Scientific Advisory Committee on Tobacco. SACTob conclusions on health claims derived from ISO/FTC method

to measure cigarette yield. Geneva: WHO, 2002, p. 4. Available at: http://www.who.int/tobacco/global_interaction/tobreg/en/iso_ftc_en.pdf

37. Trade Practices (Consumer Product Information Standards) (Tobacco) Regulations, 2004. Australia.38. Announcement no. 10, Thailand Ministry of Public Health, 2006; Personal communication from S. Benjakul, Tobacco

Control Research and Knowledge Management Center (TRC), Mahidol University, Thailand, 7 May 2007.39. In Australia and Canada, the ban arises from court-enforceable agreements between the national competition

authority and major tobacco companies.40. Ibid.41. The ban on “light” and “mild” descriptors is found in EC Directive 2001/37/EC, that has been transposed in Hungary

and Slovakia and followed in Iceland and Norway.42. In Thailand, an exception is made to allow “Mild Seven” to continue as a brand name appearing on packages.43. Personal communication from P. Šťastný & J. Potúčková, Stop fajčeniu, občianske združenie (Stop Smoking NGO,

Slovakia), 20 March 2007.44. Personal communication from E. Bianco, Research Centre of the Tobacco Epidemic, Uruguay, 27 March 2007. 45. The Smoking and Tobacco Products Usage (Control) Rules, 2006, S.R.O. no. 98-Act/2006, s.7(6), notification 30 May

2006. Bangladesh.46. Cigarettes and Other Tobacco Products (Packaging and Labelling) Rules, 2006, G.S.R. 402(E), notification 5 July 2006.

India.47. Article 4 of Act no. 465/2005 Coll on Protection of non-smokers. Slovakia.48. Personal communication from A. Ogwell, Oral and Craniofacial Research Associates, Kenya, 4 April 2007.49. Personal communication from V. LeClezio, ViSa Mauritius, 3 April 2007.50. Swanson, M.G. Australia: Health warnings canned. Tobacco Control June 2006; 15: 151.51. ACCC takes court action against British American Tobacco over Dunhill wallet pack cigarettes. Australian Competition

and Consumer Commission. Retrieved 1 June 2007 from: http://www.accc.gov.au/content/index.phtml/itemId/770572 52. Article 16.3 of the FCTC requires parties to prohibit the sale of individual cigarettes. In some countries, where

legislation has been implemented to do so, there may still be significant enforcement issues.53. Personal communication from K. Chultem, ADRA Mongolia, & T. Baljinnyam, Children, Youth, and Family Association,

Mongolia, 31 March 2007.54. Personal communication from O. Gunasekera, Alcohol and Drug Information Center, Sri Lanka, and M. Peiris, Jeewaka

Foundation, 26 March 2007.55. Personal communication from E. Bianco, Research Centre of the Tobacco Epidemic, Uruguay, 27 March 2007.

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States that are parties to the Framework Convention on Tobacco Control (FCTC) recognize that a comprehensive ban on tobacco advertising, promotion, and sponsorship would reduce the consumption of tobacco products. This recognition reflects an appreciation of the influence that tobacco advertising, promotion, and sponsorship have in stimulating demand for tobacco products,1 and the empirical evidence that shows that comprehensive bans reduce smoking rates.2

Provisions of the FCTC that Address Tobacco Advertising, Promotion, and Sponsorship - Article 13

Article 13 requires each party, in accordance with its constitution or constitutional principles, to implement a comprehensive ban of all tobacco advertising, promotion, and sponsorship. Subject to the legal environment and technical means available to that party, the comprehensive ban shall include “cross-border advertising, promotion, and sponsorship originating from its territory.” The terms tobacco advertising and promotion and tobacco sponsorship are defined very broadly in article 1 of the FCTC: “‘tobacco advertising and promotion’ means any form of commercial communication, recommendation or action with the aim, effect or likely effect of promoting a tobacco product or tobacco use either directly or indirectly” (article 1c);“‘tobacco sponsorship’ means any form of contribution to any event, activity or individual with the aim, effect or likely effect of promoting a tobacco product or tobacco use either directly or indirectly” (article 1g). In the case of a party that is not in a position to undertake a comprehensive ban due to its constitution or constitutional principles, there is an obligation to apply restrictions on all tobacco advertising, promotion, and sponsorship. These shall include, subject to the legal environment and technical means available to that party, “restrictions or a comprehensive ban on cross-border advertising, promotion and sponsorship originating from its territory with cross-border effects.” Each party must: • Prohibit all forms of tobacco advertising,

promotion, and sponsorship “that promote a tobacco product by any means that are false, misleading or deceptive or likely to create an erroneous impression about its characteristics, health effects, hazards or emissions” (article 13.4a);

• Require that “health or other appropriate warnings or messages accompany all tobacco advertising and, as appropriate, promotion and sponsorship” (article 13.4b);

• Restrict the use of “direct or indirect incentives” that encourage the purchase of tobacco products by the public (article 13.4c); and

• “Prohibit, or in the case of a Party that is not in a position to prohibit due to its constitution or constitutional principles, restrict tobacco sponsorship of international events, activities and/or participants therein” (article 13.4f).

A party that does not have a comprehensive ban on tobacco advertising, promotion, and sponsorship is required under article 13.4d to disclose to relevant government authorities “expenditures by the tobacco industry on advertising, promotion and sponsorship not yet prohibited.” These article 13.4 obligations are minimum obligations that must be complied with by each party, in accordance with its constitution or constitutional principles. The parties to the FCTC also recognize the “sovereign right” of parties to ban cross-border tobacco advertising, promotion, and sponsorship entering their territory and to impose equal penalties as those applicable to domestic advertising, promotion, and sponsorship originating from their territory (article 13.7).

Findings from the 2007 FCA FCTC Monitor: Which Countries Have Bans on Tobacco Advertising, Promotion, and Sponsorship?

Of the 27 countries participating in the 2007 FCA FCTC Monitor, data collectors from 22 (Armenia,3 Australia,4 Bangladesh,5 Canada,6 Fiji,7 Hungary,8 Iceland,9 India,10 Jordan,11 Madagascar,12 Mauritius,13 Mexico,14 Mongolia,15 New Zealand,16 Norway,17 Pakistan,18 Panama,19 Peru,20 Slovakia,21 Sri Lanka,22 Thailand,23 and Uruguay24), report having national legislation banning tobacco advertising, promotion, and sponsorship. Data collectors from four

CHAPTER 5 TOBACCO ADVERTISING, PROMOTION, AND SPONSORSHIP Jonathan Liberman

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countries (Ghana, Kenya, Palau, and Trinidad and Tobago), report having no legislation banning tobacco advertising, promotion, and sponsorship, though in each of these countries bills have been drafted. The data collector from Japan reports no national ban, with restrictions on excessive advertisements only in order to prevent minors’ smoking and health problems due to tobacco consumption. In Australia, Canada, and New Zealand, national legislation operates parallel to state, province, or local government-level legislation, which sometimes encompasses further restrictions than the national legislation. In Australia, Fiji, India, Mauritius, Norway, Pakistan, Panama, and Uruguay, discussions have taken place within government about introducing further measures.

Different Understandings of Tobacco Advertising, Promotion, and Sponsorship

Among the 22 countries with national legislation that bans tobacco advertising, promotion, and sponsorship, the breadth of the legislation varies widely. Responses we received from each country’s data collectors suggest that the terms tobacco advertising and promotion and tobacco sponsorship have been interpreted in ways that differ from the meanings given to these terms in article 1 of the FCTC and such interpretations vary widely from country to country. For example, the display of products at the point of sale is regarded in some countries as advertising or promotion. However, based on our reports, other countries do not regard this display as advertising or promotion. Similarly, unpaid depictions of smoking in popular media are sometimes regarded as advertising or promotion, but not by all countries’ data collectors. Financial contributions provided by the tobacco industry to events, organizations, or individuals, but unable to be publicized, are not always regarded as “sponsorship” for the purposes of the questionnaire. Finally, details about “indirect” promotion and sponsorship by the tobacco industry also reveal different understandings of this term – which is not surprising, given that there is no clear definition

of what “indirect” means in this context.Given the many different interpretations of what constitutes tobacco advertising, promotion, and sponsorship, and the corresponding variation in the breadth of national legislation on the issue, this chapter cannot provide quantitative or categorical comparisons between countries. Rather, it describes some of the notable responses in qualitative terms, providing a descriptive summary of the kinds of tobacco advertising, promotion, and sponsorship that continue to be observed, and of actions being taken around the world to address the issue.

Recently Observed Advertising and Promotion

Tobacco advertising and promotion occurs in many forms. In some cases, the advertising or promotion strategy seems to fall outside the scope of applicable legislation, while in others it appears to be in direct breach of the law. For examples, see table 5.1.

Tobacco advertising in print media continues to occur in Armenia and Mauritius, though with some limitations. In Armenia, the only restriction is that tobacco advertisements cannot be placed on the first or last pages of newspapers or magazines or on magazine covers.25 In Mauritius, advertisements promoting tobacco companies’ so-called

Table 5.1. Examples of tobacco advertising and promotion that continue to occur

*Note: This table outlines forms of tobacco advertising and promotion that were specifically highlighted by data collectors of participating countries. It is likely that similar activities take place in a greater number of countries than are listed here.

Type of tobacco advertising or promotion

Examples of participating countries where this occurs*

Tobacco advertising in print media Armenia, Canada, Japan, Mauritius

Billboards with tobacco advertising Bangladesh, Mexico, Peru, Trinidad & Tobago

Advertising at the point of sale Armenia, Canada, Hungary, India, Japan, Mauritius, Panama, Slovakia

Non-tobacco products that bear tobacco manufacturer’s name or brand

Canada, India, Japan, Mongolia, Norway, Palau, Slovakia

Provision of free samples of tobacco products

Armenia, Ghana, Mongolia, Pakistan

Advertising of tobacco company trade names

Armenia

Text messages via mobile phones India

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corporate social responsibility have been observed in newspapers.

Several countries have observed the sale or supply of non-tobacco products that advertise or promote tobacco products, whether through the use of a tobacco manufacturer’s name or brand or through depictions of tobacco use. Clothing is a common example of a non-tobacco product used in such a way, from articles of clothing in India with Wills and John Players branding26 to Camel boots in Norway.27 Other examples include highly visible products such as clocks (observed in Mongolia28 and Palau29) or ashtrays with tobacco company logos (observed in Canada).30

Tobacco advertising at the point of sale and provision of free samples of tobacco products are both forms of advertising and promotion that continue to occur in a number of countries, though in some cases these practices occur only in limited contexts. For example, free samples of tobacco products are provided to consumers in Pakistan at private parties.31 Similarly, tobacco is advertised at the point of sale in Canada in venues that minors cannot legally enter, such as bars.32 It should be noted that in Bangladesh, some of the bans on tobacco advertising and promotion apply to smoked tobacco products only,33 and thus smokeless tobacco continues to be advertised on television.

Restrictions Rather than Bans

In a number of countries, certain types of advertising are not banned but are restricted only in a way that as to that reduces their exposure to children or their location near health facilities. In Pakistan and Uruguay, tobacco advertising is allowed on television at certain hours – in Pakistan, between midnight and 6:00 AM,34 and in Uruguay after 10:00 PM.35 In Canada, tobacco advertising is permitted in publications that claim at least 85 percent adult readership and in direct mail to adults.36 In Mexico, billboards with tobacco advertising are allowed where they are no less than 200 metres from health facilities and 100 metres from schools; tobacco advertising using cartoons and other animation oriented to children is prohibited; and restrictions are applied to movies and magazines aimed at teenagers.37 In Panama, tobacco advertisements are allowed,

with the prior approval of the ministry of health, in magazines, publications, and films directed exclusively to adults.38 In Peru, tobacco advertising is allowed where it is directed at adults and billboard advertising is permitted where it is at least 500 metres away from schools and education centres.39

Display at Point of Sale

The data collector from Canada reports that five provinces and territories have bans on the display of tobacco products at the point of sale40 – there is no such ban nationally – and the data collectors from Iceland and Thailand report that such display is subject to a national ban.41 It appears that no such bans are in place in any of the other surveyed countries.

Types of Sponsorship Observed

A wide range of tobacco sponsorship activities was observed.42 Specific examples are provided by 17 of the 27 participating countries:

• Armenia – sponsorship of cultural events and concerts;43

• Australia – exclusivity arrangements that confer the right to promote and sell a particular cigarette brand at a cultural event or festival, such as an outdoor music festival, and funding by Philip Morris of renovations in licensed premises to create smoking areas that comply with new laws on indoor smoking;44

• Bangladesh – BAT sponsorship of tree planting and gift of a fountain to the National Press Club;45

• Canada – sponsorship of art and cultural events, though tobacco brand elements or names of manufacturers cannot be displayed in connection with these events;46

• Ghana – BAT sponsorship of reforestation, water conservation projects, and educational institutions as well as scholarships for children of employees and tobacco farmers;47

• Hungary – funding of university research projects, through third-party organizations, and foundations;48

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• India – sponsorship of arts and cultural events, fashion shows, bravery awards, and blood donation activities using tobacco company corporate identity in addition to sponsorship of activities using brand names shared with clothing such as Wills and John Player;49

• Japan – Japan Tobacco ownership of volleyball teams and sponsorship of the International Federation of Volleyball and the Japan Volleyball League, sponsorship of sports, local activities, fellowship of students from Asia, cultural activities, art, music, science, and medical research;50

• Mauritius – BAT provision of scholarships to 10 students of the University of Mauritius each year,51 sponsorship of charitable activities, job skills programs for the unemployed, and youth smoking-prevention programs;

• Mexico – sponsorship of sporting events such as car and boat racing, and adventure challenges and contests;

• Mongolia – sponsorship of sports and cultural events, sponsorship of the “Elegance” fashion show by a company importing LANDUS cigarettes, and sponsorship by the Mongol Tobacco Company of a crew of the popular television’s Channel 5 to set up direct broadcasting of the Asian Games in Doha;52

• New Zealand – funding of community activities and groups, though this cannot be advertised;53

• Panama – sponsorship of actions in national hospitals and programs for the prevention of violence against women which have not been previously authorized by the Commission of Publicity and Propaganda of the Ministry of Health;54

• Slovakia – sponsorship of a “Green Cities” program;55

• Sri Lanka – sponsorship of tsunami housing, youth smoking prevention, and sustainable development of rural societies;56

• Thailand – provision of education and research funds, sponsorship of art exhibits and cultural

projects, sponsorship of a “Youth Protecting the River” project, provision of clothing and blankets to the poor, provision of computers and teaching materials to children in rural areas, support of sales to minors programs, social services and public park construction, and founding of the “ASEAN Arts Awards,” a regional art competition (founded by Philip Morris);57 and

• Uruguay – sponsorship of art and cultural

events, philanthropic activities.58

Depictions of Smoking

In a number of the countries surveyed, there is concern about the depiction of smoking in popular culture or in advertisements for products other than tobacco products. Smoking by characters in films, such as Hollywood and/or Bollywood films, is observed in Japan, Mauritius, New Zealand, and Sri Lanka. Smoking in television shows is observed in Japan, Mexico, Mongolia, and Sri Lanka, in cartoons in Japan, and in music video clips in Mongolia, with logos and tobacco brand names sometimes being shown. In Japan, hero or heroine characters are shown smoking and brand names are sometimes shown. In Australia, publications that glamorize smoking are observed, including in advertisements for non-tobacco products such as clothing, and images of celebrities smoking.

Cross-border Tobacco Advertising, Promotion, and Sponsorship

A number of data collectors indicate that their countries’ citizens are exposed to cross-border advertising, promotion, and sponsorship that originates in other countries. Internet advertising, promotion and/or sponsorship is observed in Australia, India, Madagascar, Mauritius, Mexico, Mongolia, New Zealand, Norway, and Thailand. The broadcasting of tobacco-sponsored Formula One Grand Prix motor racing is noted in Armenia, India, and New Zealand. Advertising in foreign magazines is observed in Canada and India (where US tobacco advertising enters through US publications), and in New Zealand, Norway, and Thailand. In Mongolia, Norway, and Thailand viewers can see tobacco advertising, promotion, or sponsorship on cable or satellite television while in New Zealand tobacco advertising,

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promotion, or sponsorship is observed in DVDs and games. Tobacco advertisements on cruise ships between Norway and Denmark are noted as a problem in Norway. These examples are in addition to the depiction of smoking in films, which Mauritius, New Zealand, Sri Lanka, and Thailand note as a problem of cross-border tobacco advertising, promotion, and sponsorship.

A number of countries have legislation in place that is designed to prevent cross-border advertising, promotion, and sponsorship targeted at their country that undermines their local laws. For example, Australia allows periodicals with tobacco advertising printed outside Australia to be distributed in Australia only if they are not principally intended for distribution or use in Australia.59 Canada prohibits Canadian companies from arranging to have advertising originate in another country to promote a tobacco product in Canada.60 Fiji allows cross-border advertising into Fiji only if it is not intended for Fijian citizens.61 Sri Lanka allows incoming books, magazines, newspapers, television, and radio programs containing tobacco advertising only if these materials were not intended only or mainly for Sri Lanka.62 Thailand allows imported magazines where there is no objective to target the advertisement specifically to Thailand.63

Sanctions

Data collectors from four countries report specific details about sanctions that have been imposed as a result of breaches of tobacco advertising, promotion, and sponsorship laws. For example, in Jordan, billboards have been removed from streets and prizes (lighters, caps, t-shirts, and diaries) have been confiscated.64 In Mongolia, sanctions have been imposed on newspapers, television stations, and tobacco companies, and fines have been imposed for importing and distributing posters and various goods with tobacco brand names and for organizing lotteries promoting tobacco.65 In New Zealand, successful prosecutions have been brought against Imperial Tobacco for discounting and against Cubana Cigars in relation to advertising.66 In Thailand, the Ministry of Public Health took legal action against several convenience stores for point-of-sale advertising.67

Expenditure

Only the report from Canada indicates that there is legislation requiring the tobacco industry to disclose expenditure on tobacco advertising, promotion, and sponsorship.68

Constitutional Constraints

In Japan, it was reported that constitutional considerations may limit the availability of bans on tobacco advertising, promotion, and sponsorship because the Japanese constitution includes a guarantee of freedom of expression.69 Similar arguments were reported to have been made in Mexico. (Note that the validity of such constitutional arguments was unclear from the responses.)

Conclusion and Recommendations

According to the responses received for this monitor, tobacco advertising, promotion, and sponsorship is found in all countries, even those in which it has been substantially banned by legislation. The tobacco industry is extremely creative, and is always looking to exploit loopholes and ambiguities in legislation. The industry is also often prepared to simply breach legislation where there is no genuine threat of sanctions or where sanctions are not serious enough to act as deterrents. Based on the data collected, the following recommendations can therefore be made. Parties to the FCTC should: 1. Prioritize the development of guidelines

set by the FCTC Conference of the Parties to assist countries with implementation of their article 13 obligations. Such guidelines are urgently needed to assist countries to develop best-practice laws and enforcement practices and would be of particular assistance in informing countries of ways with which to deal with incoming cross-border tobacco advertising, promotion, and sponsorship, such as that available via the Internet.

2. Strengthen national legislation to comply with article 13 obligations.

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Notes1. Andrews, R.L., & Framke, G.R. The determinants of cigarette consumption: A meta-analysis. Journal of Public Policy

and Marketing 1991; 10: 81; US Department of Health and Human Services. Reducing the health consequences of smoking. 25 years of progress: A report of the Surgeon General. Bethesda, MD: Center for Chronic Disease Prevention and Health Promotion; Office on Smoking and Health, 1989.

2. Davis, R., Wakefield, M., Amos, A., & Gupta, P. The hitchhiker’s guide to tobacco control: A global assessment of harms, remedies and controversies. Annual Review of Public Health 2007; 28: 171-194; Saffer, H., & Chaloupka, F.J. The effect of tobacco advertising bans on tobacco consumption. Journal of Health Economics 2000; 19: 1117; Chaloupka, F.J., & Warner, K.E. The economics of smoking. Working Paper 7047. Cambridge, MA: National Bureau of Economic Research, 1999.

3. HO-394-N and HO-35-N amendments to the HO-55 law banning tobacco advertising. HO-394-N bans advertising in electronic media, effective 12 August 2002. HO-35-N amendment, adopted on 2 May 2006 bans external tobacco advertising, effective 1 October 2006. Armenia.

4. Tobacco Advertising Prohibition Act 1992 (Commonwealth). Australia. 5. Smoking and Tobacco Products Usage (Control) Act 2005. Bangladesh. 6. Tobacco Act, 1997. Canada. 7. Tobacco Control Act 1998 and Regulations 2000. Fiji. 8. Act I of 2001 amending Act 58 of 1997 on economic advertising activities. Hungary.9. Tobacco Control Act no. 6/2002. Iceland.10. Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce,

Production, Supply and Distribution) Act, 2003, and Rules made thereunder. India. 11. Public Health Law no. 21 for the year 1971. New stringent regulations started when the FCTC entered into force.

Jordan. 12. Interministry Decree no. 18 171/2003. Madagascar. 13. Public Health (Restrictions on Tobacco Products) Regulations 1999. Mauritius. 14. Reglamento de la Ley Gral de Salud en Materia de Publicidad, DOF 06/04/2006, articles 36 and 37. Mexico. 15. The Law of Mongolia on Tobacco Control. 16. Smoke-free Environments Act 1990. New Zealand. 17. Prevention of the Harmful Effects of Tobacco, 1973. Norway. 18. Prohibition of Smoking in Enclosed Places and Protection of Non-smokers Health Ordinance, 2002. Pakistan. 19. Executive Decree 17 of 11 March 2005, by which measures for the prevention and reduction of the consumption and

exposure from the smoke of tobacco products are dictated, by its injurious effects in the health of the population. Panama.

20. Law 28705 for Prevention and Control of Tobacco Consumption, 2004. Peru. 21. Act no. 147/2001 on advertising and change and amendment of some laws. Slovakia. 22. NATA Act, no. 27/2006, sections 35, 36, and 37. Sri Lanka. 23. Tobacco Products Control Act, 1992. Thailand. 24. Decree 170/005, 31 May 2005. Uruguay.

3. Broaden legislative definitions of “tobacco advertising and promotion” and “tobacco sponsorship” to cover the use of company names and trade names, and not just brand names, trademarks, and logos.

4. Apply legislation across all types of media, public venues, and outlets, including retail outlets.

5. Reinforce legislation with sanctions that can deter. This means both that the available sanctions are serious enough to deter and that they are imposed in practice.

6. Ban tobacco advertising, promotion, and sponsorship, unless constitutional

limitations apply, rather than just restricting it. Measures that aim to limit exposure of children to tobacco advertising, promotion, and sponsorship, but that still allow advertising, promotion, and sponsorship to continue in forms that predominantly target adults, breach article 13 obligations.

7. Mandate disclosure by the tobacco industry of its expenditure on any forms of tobacco advertising, promotion, and sponsorship. Such legislation is needed to allow countries to adequately monitor the industry’s advertising, promotion, and sponsorship practices and take appropriate measures to respond to and deter such practices in the future.

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25. HO-394-N (2002) and HO-35-N (2006) amendments to the HO-55 law on advertisement. Armenia. 26. Reddy, K.S., & Gupta, P.C. (Eds.). Report on tobacco control in India. New Delhi: Ministry of Health and Family Welfare

and WHO, 2004; Burning Brain Society, retrieved 15 March 2007 from: http://www.burningbrain.org ; ITC Limited retrieved 14 March 2007 from: http://www.itcportal.com ; images and pictures available at: http://gallery.globalink.org/v/members/goswamih/

27. Personal communication from B. Rosted, Norwegian Cancer Society, 12 March 2007.28. Association of Mongolian Public Health Professionals. Assessment of the conformity of national policies with the

Framework Convention on Tobacco Control in Mongolia. Ulaanbaatar: Association of Mongolian Public Health Professionals, 2006; p. 11.

29. Personal communication from C. Otto and A. Lyman, Coalition for a Tobacco-Free Palau, 15 March 2007.30. Personal communication from M. DeRosenroll, Canadian Cancer Society, 23 March 2007.31. Prohibition of Smoking in Enclosed Places and Protection of Non-smokers Health Ordinance, 2002. Pakistan. 32. Tobacco Act, 1997. Canada. 33. Smoking and Tobacco Products Usage (Control) Act, 2005. Bangladesh. 34. Prohibition of Smoking in Enclosed Places and Protection of Non-smokers Health Ordinance, 2002. Pakistan. 35. Decree 170/005, 31 May 2005. Uruguay. 36. Tobacco Act, 1997. Canada. 37. Reglamento de la Ley Gral de Salud en Materia de Publicidad, DOF 06/04/2006, articles 36 & 37. Mexico. 38. Executive Decree 17 of 11 March 2005, by which measures for the prevention and reduction of the consumption and

exposure to the smoke from tobacco products are dictated, by its injurious effects in the health of the population. Panama.

39. Law 28705 for Prevention and Control of Tobacco Consumption, 2004. Peru. 40. Personal communication from M. DeRosenroll, Canadian Cancer Society, 23 March 2007 and Canadian Council for

Tobacco Control, legislation on display bans. Available at: http://www.cctc.ca/cctc/EN/bandisplays/legislation41. Tobacco Control Act no. 6/2002. Iceland. 42. As noted earlier, “tobacco sponsorship” is defined in article 1 of the FCTC as “any form of contribution to any event,

activity, or individual with the aim, effect or likely effect of promoting a tobacco product or tobacco use either directly or indirectly.”

43. Personal communication on television reports from N. Movsisyan, American University of Armenia, 3 April 2007.44. Australian Capital Territory (ACT) Tobacco Act 1927, NSW Public Health Act 1991, Northern Territory Tobacco Control

Act, Qld Tobacco and other Smoking Products Act 1998, South Australia Tobacco Products Regulation Act 1997, Tasmania Public Health Act 1997, Victoria Tobacco Act 1987, Western Australia Tobacco Products Control Act 2006; personal communication from K. Lindorff, VicHealth Centre for Tobacco Control, Australia, 26 March 2007. Based on organizational research and observation, Australian national media articles.

45. Personal communication on NGO monitoring from S.M. Alam Tahin, WBB Trust (Work for a Better Bangladesh), 15 March 2007.

46. Personal communication based on observations by Physicians for a Smoke-Free Canada, 2006-2007 from M. DeRosenroll, Canadian Cancer Society, 23 March 2007.

47. BAT Ghana Annual Report and Financial Statements (2005), pp. 12-13. 48. Personal communication from T. Szilágyi, Health 21 Hungarian Foundation, 15 March 2007.49. Reddy, K.S., & Gupta, P.C. (Eds.), Report on Tobacco Control in India. New Delhi: Ministry of Health and Family Welfare

and WHO, 2004; Burning Brain Society, retrieved 15 March 2007 from: http://www.burningbrain.org ; ITC Limited retrieved 14 March 2007 from: http://www.itcportal.com ; Godfrey Phillips India Limited retrieved 15 March 2007 from: http://godfreyphillips.com/news.asp

50. Japan Tobacco available at: http://www.jti.co.jp/JTI_E/51. “BAT gives university grants to ten students.” L’express 17 August 2004. Available at: http://www.lexpress.mu/

display_search_result.php?news_id=24170.52. Advertisement Agency of TV Channel 5, television report, December 2006; Association of Mongolian Public Health

Professionals. Assessment of the conformity of national policies with the Framework Convention on Tobacco Control in Mongolia. Ulaanbaatar: Association of Mongolian Public Health Professionals, 2006; p. 10.

53. Thomson, G. Trust us – We’re socially responsible. The truth behind British American Tobacco NZ’s corporate social responsibility reports. Newmarket, NZ: Action on Smoking And Health New Zealand, 2005. Available at: http://www.ash.org.nz

54. Personal communication from R. Roa, Coalición Panameña Contra el Tabaquismo (COPACET), 21 March 2007 based on Panama national media, including photos and articles.

55. Personal communication from P. Šťastný and J. Potúčková, Stop fajčeniu, občianske združenie (Stop Smoking NGO), 20 March 2007. Based on observations of Slovakia mass media in 2006.

56. Personal communication from O. Gunasekera, Alcohol and Drug Information Center, Sri Lanka, and M. Peiris, Jeewaka Foundation, 26 March 2007. Based on Ceylon Tobacco Company, Annual report 2005.

57. Thailand Tobacco Monopoly, Annual report 2005 pp. 68 and 77; Thai and US youth crash Philip Morris ASEAN Arts Awards. Available at: http://www.essentialaction.org/tobacco/event/asean04

58. Personal communication from E. Bianco, Research Centre for the Tobacco Epidemic in Uruguay, 27 March 2007.59. Tobacco Advertising Prohibition Act, 1992. Australia. Available at: http://www.austlii.edu.au/au/legis/cth/consol_act/

tapa1992314/60. Tobacco Act, 1997. Canada.61. Tobacco Control Act 1998 and Regulations 2000. Fiji. 62. NATA Act, no. 27/2006, section 35. Sri Lanka.

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63. Tobacco Products Control Act, 1992. Thailand. 64. Ministry of Health, Public Health Law. (updated, no year available). Jordan. 65. The Intellectual Property Office of Mongolia, Register of Penalties Imposed on Illegal Advertisement of Tobacco 2004-

2006; The State Specialized Inspection Agency. Report on nation-wide inspection on implementation of the law on tobacco control. Ulaanbaatar: September 2006; pp. 5-6.

66. Personal communication from M. Allen, Smoke-free officer, Canterbury, 26 March 2007; New Zealand Ministry of Health, media release 17 December 2002. Available at: http://www.moh.govt.nz/moh.nsf ; personal communication from J. Stribling, Ministry of Health, 26 March 2007.

67. Discussion of the Tobacco Research Center Working Group, 13 March 2007, Thailand; Guidelines practiced for tobacco retail stores under point-of-sales display regulations. Retrieved 8 June 2007 from: http://www.thaiantitobacco.com

68. Personal communication from M. DeRosenroll, Canadian Cancer Society, 23 March 2007. Tobacco reporting regulations. Canadian Legal Information Institute. Retrieved March 2007 from: http://www.canlii.org/ca/regu/sor2000-273/

69. Article 21, 1946, Constitution of Japan.

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Although most tobacco control measures, including smoke-free environments, price and tax increases, advertising bans, large warning labels, and information campaigns successfully increase the number of smokers trying to quit, only a small proportion of smokers manage to stop smoking unaided. Tobacco use is recognized as an addiction by both the World Health Organization and the American Psychiatric Association.1 Tobacco dependence treatment to help smokers to quit, including increased access to medications, has been identified as one of six effective tobacco control interventions by the World Bank, and is strongly supported by scientific evidence.2

Tobacco dependence treatment is effective and highly cost effective. Very few smokers are able to quit spontaneously—between 1 and 3 percent as reported by the Royal College of Physicians of London—but abstinence rates among smokers who receive treatment reach around 20 percent for intensive support plus medication.3 Treating dependent smokers is one of the most cost effective medical interventions that produces population health gain.4,5

Article 14 of the FCTC: Tobacco Dependence Treatment

Under the broad heading “demand reduction measures concerning tobacco dependence and cessation,” article 14 of the Framework Convention on Tobacco Control requires parties to “develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities” and to “take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence.”6

Towards this end, parties shall “endeavour to:a. design and implement effective programs

aimed at promoting the cessation of tobacco use, in such locations as educational institutions, health care facilities, workplaces and sporting environments;

b. include diagnosis and treatment of tobacco dependence and counselling services on cessation of tobacco use in national health and education programs, plans and strategies, with the participation of health workers, community workers and social

workers as appropriate; c. establish in health care facilities and

rehabilitation centres programs for diagnosing, counselling, preventing and treating tobacco dependence; and

d. collaborate with other Parties to facilitate accessibility and affordability for treatment of tobacco dependence including pharmaceutical products pursuant to Article 22. Such products and their constituents may include medicines, products used to administer medicines and diagnostics when appropriate.”7

This chapter reports the responses of data collectors from 27 countries to 10 questions in the 2007 FCA FCTC Monitor about tobacco dependence treatment policy and practice.

A Note on Terminology

Because there is potential confusion over use of the terms smoking cessation and tobacco dependence treatment, this chapter uses the definition of treatment from the World Health Organization’s European guidelines: “Tobacco dependence treatment includes (singly or in combination) behavioural and pharmacological interventions such as brief advice and counselling, intensive support, and administration of pharmaceuticals, that contribute to reducing or overcoming tobacco dependence in individuals and in the population as a whole.”8

Smoking cessation refers to all activities that promote or support cessation, which include health education and public information campaigns, price increases, smoke-free environments, and so on. Tobacco dependence treatment is the narrower activity of helping and supporting individuals overcome their dependence on nicotine. For the sake of brevity, the term smoking, where used, should be taken to include all tobacco use.

Findings from the 2007 FCA FCTC Monitor: Which Countries Have Treatment for Tobacco Dependence?

The responses to the main questions for the 27 countries participating in the 2007 FCA FCTC Monitor are summarized in table 6.1 to provide an overview of which countries have which

CHAPTER 6 TOBACCO DEPENDENCE TREATMENTMartin Raw

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treatment policy components. Data collectors from participating countries were asked if their countries have an official government policy on treatment, if they have treatment guidelines, and if so whether the guidelines are comprehensive, if they have an official treatment lead person, if they have a national specialist treatment system, and if they have a national telephone quitline. Tables 6.4 to 6.6 report responses to the questions about stop smoking medications and reimbursement for treatment.

The 2007 FCA FCTC Monitor questions:7.1 Does country have official written policy on

tobacco dependence treatment? 7.3 Does country have clinical guidelines

formally endorsed by at least one prestigious health care professional body?

7.3.f Are the guidelines for all health professionals (i.e., the whole health care system)?

7.4 Has country taken measures to promote cessation? (wording from article 14).

7.5 Has country taken measures to provide adequate treatment? (wording from article 14).

7.6 Is there an officially identified person in government (or contracted by government) who manages or oversees treatment services?

7.7 Does country have a specialized treatment system delivered by trained professionals, covering whole country?

7.8 Does country have a national telephone quitline, in all major regions of the country?

National Policies on Treatment, Treatment Guidelines, and Official Treatment Lead

In this section responses are reported to four questions from the treatment section of the 2007 FCA FCTC Monitor. Data collectors were asked if their respective countries have an official written government policy on tobacco dependence treatment and if yes, what does it include; if their countries have clinical treatment guidelines formally endorsed by at least one prestigious health professional body; and if there is an officially identified person in government (or contracted by the government) who oversees or manages the treatment services. Table 6.2 shows which countries have an official written government policy on treatment, and which have clinical treatment guidelines formally endorsed by at least one prestigious health professional body.

Official policy. From the 27 participating countries, eight data collectors (Canada, Hungary, India, Japan, Jordan, Mexico, Norway, and Thailand) report that their country has an official written government policy on treatment and 19 report that their country does not have such a policy. Of the eight with an official government policy on treatment, most say that the policy includes a strategy on training, a strategy to support interventions by primary care professionals, and a policy to promote the use of medications. Only two say the policy includes specialist treatment services or telephone quitlines. However, the detailed response from the Mexican data collector makes it clear that although stop smoking medications

7.1 7.3 7.3.f 7.4 7.5 7.6 7.7 7.8

Armenia yes

Australia yes yes yes yes yes

Bangladesh

Canada yes yes yes yes yes

Fiji yes yes

Ghana yes

Hungary yes yes yes yes yes yes

Iceland yes yes

India yes yes yes

Japan yes yes yes yes

Jordan yes yes yes

Kenya yes

Madagascar yes

Mauritius

Mexico yes yes yes yes

Mongolia yes yes yes yes

New Zealand yes yes yes yes yes

Norway yes yes yes yes yes yes yes

Pakistan yes

Palau yes yes yes

Panama yes yes

Peru yes

Slovakia yes yes yes yes yes yes

Sri Lanka yes

Thailand yes yes yes yes yes yes

Trinidad & Tobago

yes

Uruguay yes yes yes yes

Table 6.1. Summary of key answers by country

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are supposed to be provided by public health institutions, they rarely are in practice, a situation that may be common. This question almost certainly measures aspiration more than actual practice at the moment, but intention is important and at least reflects a country’s desire to implement article 14.

Clinical guidelines. Eleven data collectors (Australia, Canada, Hungary, Japan, Mexico, Mongolia, New Zealand, Norway, Panama, Slovakia, and Thailand) report that their country has clinical treatment guidelines formally endorsed by at least one prestigious health professional body, and 16 say they do not have such guidelines. Among the 11 countries with clinical treatment guidelines, all data collectors report that the guidelines are for doctors. Four say that the guidelines are also for nurses, while only two say that the guidelines are for pharmacists and two for dentists. Only the data collectors from New Zealand and Thailand report that the guidelines are for all health professionals, that is, for the whole health care system.

The answers to this question range from a country that has just one centre in one city that has its own internal guidelines (Ulaanbaatar, Mongolia), to countries like Australia and New Zealand that have national guidelines endorsed by many prestigious professional bodies,

22 in New Zealand’s case.9 The guidelines reference group for the Australian guidelines includes the Royal Australian College of General Practitioners, the Cancer Council Australia, National Heart Foundation, Australian Divisions of General Practice, New Zealand Guidelines for Smoking Cessation Advisory Group, and the University of Sydney Family Medicine Research Centre.10

Twelve data collectors report that their country has an official treatment lead and 15 report they do not. The following countries have an official treatment lead: Canada, Hungary, India, Japan, Jordan, Mongolia, New Zealand, Norway, Palau, Slovakia, Thailand, and Uruguay.

Measures to Promote Cessation and Provide Adequate Treatment

The wording of questions 7.4 and 7.5 is taken directly from the wording of article 14: “Has country X taken measures to promote cessation of tobacco use”; “Has country X taken measures to provide adequate treatment for tobacco dependence.”

Twenty-three (out of 27) data collectors report that their country has taken measures to promote cessation of tobacco use. Nine say that the measures are comprehensive and national. Most (20) say that these measures target health care facilities, 13 that they target educational institutions, 10 workplaces, and 6 that they target sporting environments. The question asked about any measure that promotes cessation, which includes almost all tobacco control policies, including health education and public information, and so the high positive response rate is unsurprising. More surprising, perhaps, is that three country data collectors answer “no” to this question: Bangladesh, Mauritius, and Peru. Nine data collectors report that their country has taken measures to provide adequate tobacco dependence treatment and 16 that it has not. It is not easy to interpret the positive responses since the word adequate is not defined, but again, it is notable that so many respondents say that their country has not taken adequate treatment measures. At the very least then, responses to these questions reveal that most countries are not yet implementing the treatment provisions of article 14 of the FCTC.

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Table 6.2. Countries with/without an official written government policy on treatment, and with/without clinical treatment guidelines.

Official policy Clinical guidelines

Yes (n=8) No (n=19) Yes (n=11) No (n=16)

CanadaHungaryIndiaJapanJordanMexicoNorwayThailand

ArmeniaAustraliaBangladeshFijiGhanaIcelandKenyaMadagascarMauritiusMongoliaNew ZealandPakistanPalauPanamaPeruSlovakiaSri LankaTrinidad & TobagoUruguay

AustraliaCanadaHungaryJapanMexicoMongoliaNew ZealandNorwayPanamaSlovakiaThailand

ArmeniaBangladeshFijiGhanaIcelandIndiaJordanKenyaMadagascarMauritiusPakistanPalauPeruSri LankaTrinidad & TobagoUruguay

47


Specialized Tobacco Dependence Treatment System and Quitlines

Data collectors were asked if their country has “a specialized treatment system (experts or units/clinics) offering individual or group support delivered by trained professionals” and if their country has “a telephone quitline.”

Specialized treatment system. Five data collectors (Australia, Norway, Slovakia, Thailand, Uruguay) report that their country has a specialized treatment system covering the whole country (i.e., all smokers have access). Three report a network but only in selected areas, nine report having just a few centres, and ten report no treatment system at all. Thus very few countries offer treatment support to all smokers which, admittedly, is a demanding goal.

However, even in countries with a treatment system with national coverage, full use is not always being made of the resources available. In Uruguay, for example, all national health institutions and organizations can get free stop smoking medications from the government, but in spite of this not all have applied for them.11

Telephone quitline. Eight data collectors (Australia, Canada, Hungary, Iceland, Mexico, New Zealand, Norway, Slovakia) report that their country has a national quitline, or quitlines covering all major regions, and three report having a patchwork of small, local quitlines. Thirteen state their country does not have quitlines and three say they are planning them. The data collectors in the 11 countries that said that they have national or local quitlines, were asked details about how they are run. Their answers are summarized in table 6.3.

The reported quality of the quitlines is impressive. The majority have a person answering calls, rather than recorded messages (for which there is very little evidence of efficacy), and offer multiple support sessions, including counsellors calling back and referrals to local treatment services, and 73% offer free calls. Because of the popular uptake of mobile phones, quitlines will enable us to reach many people in low-income countries that have little access to face-to-face treatment services.

Medications

The final two treatment questions asked about the availability and licensing of medications, and about reimbursement of tobacco dependence treatment, including behavioural support and medications. Data collectors were asked if the following medications are available in their country, how they are licensed, and if they can be advertised on television. The availability data are shown in table 6.4 with the data on licensing appearing in table 6.5.

The only commonly available medications are nicotine replacement therapy (NRT), in particular the gum and patch, and bupropion. Varenicline is not yet widely available because it was only launched in 2006 (in the USA). License applications are probably under way in many countries now so it should be much more available in a few years.

Very few countries permit stop smoking medications on general sale (i.e., available in

Does the quitline have/provide: yes no

A person answering (always or almost always)

9 2

Mostly recorded messages 3 7

A line toll free to callers 7 4

Multiple support sessions, counsellors calling back to offer support

8 3

Referrals to local specialist treatment services

10 1

Medications to help callers stop 4 6

Note: where the rows don’t add up to 11, the data collectors were “unable to determine.”

Table 6.3. Characteristics of quitlines (n=11)

yes no

NRT (gum) 22 4

NRT (patch) 21 5

NRT (sublingual tablet) 5 18

NRT (lozenge) 7 17

NRT (inhalator) 8 16

NRT (nasal spray) 3 21

Bupropion 18 8

Varenicline 8 17

Cystisine 4 18

Other 5 15

Notes: n=27; where the rows don’t add up to 27, the data collectors were “unable to determine”;bupropion=Zyban; varenicline=Chantix/Champix; and Cystisine=Tabex.

Table 6.4. Availability of medications

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any shop, for example, supermarkets) and the few that do typically permit mainly nicotine gum and patches (one country has the lozenge on general sale and one country has the inhalator). A majority of countries allow the sale of nicotine gum and patches through pharmacies (called “over-the-counter” sales in some countries) but very few countries allow the sale of any of the other medications through pharmacies. Only bupropion is available by a doctor’s prescription in a majority of countries (16), with varenicline available by prescription in just 11 countries and very few other medications available through prescription in many countries. Finally, only nicotine gum and patches can be advertised on television in a significant number of countries.

At the end of this section of the questionnaire, data collectors were asked if each treatment intervention (brief advice/support, intensive specialist support, medications) is free of charge or fully reimbursed to users by the health care system or other third party payers.The vast majority of participating countries do not reimburse any of the medications at all. Twelve out of 27 countries (44%) fully or partially reimburse brief advice/support and 6 out of 27 (22%) fully or partially reimburse intensive specialist support. The general picture on reimbursement then reflects the broader picture on implementation of adequate treatment provision: it is not available in most countries.

Summary of Responses on Specialized Treatment Services, Quitlines, Medications, and Reimbursement

These data show that tobacco dependence treatment is a low priority for most of the countries surveyed. The data show:• Very few countries have a treatment system

with national coverage.• Very few countries have a telephone quitline

with national coverage.• Most countries have made nicotine gum,

nicotine patches, and bupropion available.• NRT is fully reimbursed in only two countries

and bupropion in only one.• Most countries have

no reimbursement at all for any of the medications.

• Fewer than half reimburse brief advice/support or intensive specialist support.

• Very few countries provide NRT through doctors’ prescription.

• Only nicotine gum and patches are (moderately) widely advertised on television.

General sale, e.g. supermarkets

From pharmacies (over the counter)

Doctor’s prescription

Can advertise on television

yes no yes no yes no yes no

NRT (gum) 6 17 17 5 6 20 12 8

NRT (patch) 6 17 16 6 6 20 11 9

NRT (sublingual tablet)

0 16 4 14 5 21 6 11

NRT (lozenge) 1 16 4 14 4 22 5 13

NRT (inhalator) 1 16 4 14 6 20 7 13

NRT (nasal spray) 0 17 2 16 2 24 4 14

Bupropion 0 20 6 14 16 10 4 17

Varenicline 0 17 3 13 11 15 3 17

Cystisine 0 17 4 13 4 22 3 15

Other 0 14 3 13 4 22 3 12

Note: n=27; where the rows don’t add up to 27, the data collectors were “unable to determine.”

Table 6.5. Licensing of medications

total partial no

NRT (gum) 2 1 21

NRT (patch) 2 1 21

NRT (sublingual tablet) 0 0 21

NRT (lozenge) 0 0 20

NRT (inhalator) 0 0 20

NRT (nasal spray) 0 0 21

Bupropion 1 2 20

Varenicline 0 0 21

Cystisine 0 0 19

Other 0 0 19

Brief advice/support 8 4 11

Intensive specialist support 4 2 13

Note: n=27; where the numbers don’t add up to 27, the data collectors were “unable to determine.”

Table 6.6. Reimbursement of treatment

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• Fewer than a quarter of surveyed countries permit NRT on general sale.

Conclusions

We don’t know why treatment is such a low priority but it seems likely to be at least partly because of its cost or perceived cost. This is especially likely to be true of the medications but it is disappointing that brief advice and support is reimbursed in so few countries. Brief advice is an extremely cost effective intervention in producing population health gain12 and is also an extremely cheap intervention. It ought to be part of routine health care in every country.

Leaving aside cost considerations for the moment, certain treatment provisions can be considered ideal. Ideally, a country should have:

• a national telephone quitline with a person answering, providing call-back counselling, and multiple support sessions;

• all health professionals trained and reimbursed to raise the issue, give brief advice when appropriate, and refer to specialist treatment services;

• smoking status routinely recorded in all medical notes;

• a specialist treatment service which is part of the country’s national health care system, in the same way as any other secondary treatment service is;

• the provision of all effective medications through doctors’ prescription;

• the provision of NRT through broader channels like general sale.

In terms of robust scientific evidence, most of the medications are of similar effectiveness13 and so ideally all should be available, which would allow tobacco users a choice.Reimbursement is also fundamentally important because stop smoking medications (and behavioural support if they have to pay) are typically more expensive than cigarettes for many smokers, and are simply beyond their ability to pay.

Only 12 of the 27 countries have an official treatment lead (in government or contracted by government), which is disappointing and suggests that, in many countries, we still need

to persuade government to take treatment seriously enough to appoint an official lead. And since 12 countries have a treatment lead but only 8 have official policies on treatment, it seems that another priority is for each country to have an official treatment policy. The fact that more countries have professionally endorsed treatment guidelines than official government policies may reflect an important historical lesson—that health professionals rather than government officials tend to lead when it comes to arguing for treatment services. This suggests that each country needs not just an official government lead on the subject but ought to have a lead nongovernmental organization, or person in an NGO to advocate treatment and, ideally, to work with government.

Recommendations

To countries:

1. Appoint an official lead on tobacco dependence treatment.

2. Develop a national policy on treatment.3. Develop comprehensive, national, evidence

based treatment guidelines endorsed by prestigious national health professional organizations.

4. Fund a national quitline answered by people with multiple sessions of call-back counselling.

5. Make all stop smoking medications as widely available as possible, including making them as cheap as possible to tobacco users.

To the Conference of the Parties:

6. Develop guidelines to help countries interpret “adequate treatment for tobacco dependence treatment.”

7. Develop a template to show countries what would be ideal treatment provision and what measures they might prioritize if they have limited resources.

8. Provide technical support for countries to help them develop and implement effective treatment policies.

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Notes1. Royal College of Physicians Tobacco Advisory Group. Nicotine addiction in Britain. London: Royal College of Physicians,

2000. Available at: http://www.rcplondon.ac.uk/pubs/books/nicotine/index.htm2. Joossens, L., & Raw, M. The tobacco control scale: A new scale to measure country activity. Tobacco Control 2006;

15: 247-253. Available at: http://tc.bmjjournals.com/cgi/reprint/15/3/2473. Royal College of Physicians Tobacco Advisory Group. Nicotine addiction in Britain.4. Parrott, S., Godfrey, C., Raw, M., West, R., & McNeill, A. Guidance for commissioners on the cost-effectiveness of

smoking cessation interventions. Thorax 1998; 53(Suppl. 5, part 2): 1-35. 5. West, R., McNeill, A., & Raw, M. Smoking cessation guidelines for health professionals: An update. Thorax 2000; 55:

987-999. Available at: http://thorax.bmjjournals.com/cgi/content/full/55/12/9876. World Health Organization, Framework Convention on Tobacco Control, article 14.1.7. WHO, FCTC article 14.2.8. Raw, M., Anderson, P., Dubois, G. et al.. WHO evidence-based recommendations on the treatment of tobacco

dependence. Tobacco Control 2002; 11: 44. Available at: http://tc.bmjjournals.com/cgi/content/full/11/1/44 9. Guidelines for Smoking Cessation. New Zealand Guidelines Group. Available at: http://www.nzgg.org.nz/guidelines/

dsp_guideline_popup.cfm?&guidelineID=2510. They were published by the Australian Government Department of Health and Ageing, June 2004. Available at: http://

www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-pubhlth-publicat-document-smoking_cessation-cnt.htm/$FILE/smoking_cessation.pdf

11. Personal communication from E. Bianco, Research Center of the Tobacco Epidemic, Uruguay, 27 March 2007.12. Royal College of Physicians Tobacco Advisory Group. Nicotine addiction in Britain.13. Parrott, S., et al. Guidance for commissioners on the cost-effectiveness of smoking cessation interventions.

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Each party to the Framework Convention on Tobacco Control recognizes that the elimination of all forms of illicit trade in tobacco products, including smuggling and illegal manufacturing, is an essential component of tobacco control. They recognize that smuggled and counterfeit cigarettes are sold at lower prices, making cigarettes available cheaply, thereby increasing consumption and undermining efforts to keep young people, in particular, from smoking.

In 2000, a report commissioned by the World Bank estimated that between 6 percent and 8.5 percent of all cigarette consumption involved smuggled cigarettes. The 6 percent estimate was based on import and export statistics and was mainly an estimate for large-scale smuggling. The 8.5 percent estimate was based on estimates of smuggling (bootlegging and large-scale smuggling) as a percentage of 1995 domestic sales by using different expert sources.1

Given the nature of illicit tobacco trade as illegal conduct, estimates of the size of the trade are seldom precise so some caution is necessary. In a recent report, the Framework Convention Alliance (FCA) collected the most recent estimates of illicit tobacco trade from a number of countries around the world.2 Based on that data, the FCA estimates that the global illicit cigarette trade represents approximately 10.7 percent of global sales, or approximately 600 billion cigarettes annually.3

Illicit trade in tobacco products occurs through large-scale smuggling, bootlegging, and counterfeiting and illegal manufacturing. The smuggling of tobacco occurs through both large- and small-scale operations.4 Large-scale organized smuggling involves the illegal transportation, distribution, and sale of large consignments of cigarettes and other tobacco products, generally avoiding all taxes. Large-scale smuggling of this nature often also involves industry complicity and organized crime networks. Smaller-scale smuggling or “bootlegging” refers to activities of individuals or small gangs who illegally import small quantities of products. It involves, for instance, the purchase of cigarettes and other tobacco products in low-tax jurisdictions in amounts that exceed the limits set by customs regulations, for resale in high-tax

jurisdictions. Significant price differentials between jurisdictions create the incentives for bootlegging. Illegal manufacturing refers to the production of cigarettes contrary to law.5 The laws in question may be taxation laws or other laws (such as licensing or monopoly-related laws) that restrict the manufacture of tobacco products. Counterfeit tobacco production is also a form of illegal manufacturing, in which the manufactured products bear a trademark without the consent of the owner of the trademark.

Provisions of the FCTC that Address Illicit Trade of Tobacco Products - Article 15

Under article 15, parties to the FCTC “recognize that the elimination of all forms of illicit trade in tobacco products, including smuggling, illicit manufacturing and counterfeiting, and the development and implementation of related national law, in addition to subregional, regional and global agreements, are essential components of tobacco control.” As such, parties have accepted a wide range of obligations to facilitate the elimination of illicit trade.

Documentation and control of the movement of tobacco products

Under article 15.2, each party to the FCTC is required to adopt and implement effective measures to: “ensure that all unit packets and packages of tobacco products and any outside packaging of such products are marked to assist Parties in determining the origin of tobacco products”; assist parties in determining the “point of diversion”; and “monitor, document, and control the movement of tobacco products and their legal status.” Each party must also “require that unit packets and packages of tobacco products for retail and wholesale use that are sold on its domestic market carry the statement: ‘sales only allowed in (insert name of the country, sub-national, regional or federal unit)’ or carry any other effective marking indicating the final destination or which would assist authorities in determining whether the product is legally for sale on the domestic market” (article 15.2a). Each party must require that such packaging information and marking be “presented in a legible form and/or appear in its principal language or languages” (article 15.3).

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Each party is also required, with “a view to eliminating illicit trade in tobacco products,” to “monitor and collect data on cross-border trade in tobacco products, including illicit trade, and exchange information among customs, tax and other authorities, as appropriate, and in accordance with national law and relevant applicable bilateral or multilateral agreements” (article 15.4a); and to “adopt and implement measures to monitor, document and control the storage and distribution of tobacco products held or moving under suspension of taxes or duties within its jurisdiction” (article 15.4d).

Legislation against illicit trade

Under article 15.4b, each party is required, with “a view to eliminating illicit trade in tobacco products,” to “enact or strengthen legislation, with appropriate penalties and remedies, against illicit trade in tobacco products, including counterfeit and contraband cigarettes.”

Confiscated goods, equipment, and proceeds

Each party is required, with “a view to eliminating illicit trade in tobacco products,” to “take appropriate steps to ensure that all confiscated manufacturing equipment, counterfeit and contraband cigarettes and other tobacco products are destroyed, using environmentally friendly methods where feasible, or disposed of in accordance with national law” (article 15.4c). Each party must also “adopt measures as appropriate to enable the confiscation of proceeds derived from the illicit trade in tobacco products” (article 15.4e).

Reporting

Article 15.5 requires that information collected by parties pursuant to articles 15.4a and 15.4d “shall, as appropriate, be provided in aggregate form by the Parties in their periodic reports to the Conference of the Parties, in accordance with Article 21.”

Cooperation

Article 15.6 requires each party to “promote cooperation between national agencies, as well as relevant regional and international intergovernmental organizations as it relates to

investigations, prosecutions and proceedings, with a view to eliminating illicit trade in tobacco products.”

Findings from the 2007 FCA FCTC Monitor: Which Countries Are Addressing Illicit Trade of Tobacco Products?

Data collectors from 21 of the countries participating in the FCA FCTC Monitor report that their countries have a problem with illicit trade of tobacco products. Data collectors from island nations such as Japan, Iceland, New Zealand, and Trinidad and Tobago say that their countries have no problems with illicit trade and Mexico’s data collector says that it has only a minor problem (the illegal market was less than 5% of the total). In Mauritius it is estimated that 10 percent of the cigarettes available on the local market are smuggled.6 In Mongolia the estimate for the illegal tobacco market was around 21 percent in 2006 according to customs.7 The Australian National Audit Office and the Australian Taxation Office have assessed the current risk of illegal tobacco operations as severe.8 In Pakistan there is a huge influx of smuggled cigarettes from borders with Iran and Afghanistan. According to Pakistan customs, the illegal tobacco trade represented 17 percent of cigarette sales in Pakistan in 2005.9

Data collectors from 14 of the 27 participating countries report that measures have been introduced to determine the origin of tobacco products. In addition, four countries have introduced statements on the packages to indicate that “sales [are] only allowed in” that specific country, which accords with article 15.2 of the FCTC. For instance in Thailand, locally produced cigarettes and imported cigarettes must bear a statement indicating that sales of the cigarettes are only allowed in the Thai kingdom. In addition, every packet of locally produced cigarettes is covered with a revenue stamp for tobacco on the top of the cigarette pack.10

Fourteen of the 27 data collectors report that legislation has been introduced to reduce illicit tobacco trade. A good example is Australia where all the tobacco trade is under licence: cigarette manufacturers and those who produce or deal in tobacco seed, plant, or leaf

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in Australia must be licensed, and record-keeping requirements are individually imposed on licensed persons. Excise duty must be paid in respect of tobacco leaf that is unaccounted for. Permission is required to move tobacco leaf, seed, or plant. Authorities have control over the delivery of excisable goods for export. The customs office has control over excisable goods that are imported for use in the manufacture of excisable goods (such as manufactured cigarettes) for extended periods.11

In Mongolia legislative measures to reduce illicit trade in tobacco products include separate licensing for tobacco import, trade, and manufacture (combined with tobacco leaf planting).12 Furthermore, legislation requires that excise tax stamps be attached on all imported and manufactured tobacco products in addition to mandatory reporting of tobacco import quantity to tax and customs offices, confiscation of illicit tobacco products, and sanctions for violating these regulations.13 However, a September 2006 nation-wide inspection revealed that in practice the government system was not functioning as intended. Since local governors did not issue licences to sell tobacco, most points of tobacco sale went unregistered. The government had not renewed any licences for tobacco import, nor approved the state tender to license manufacture of tobacco products and tobacco planting.14 Therefore, in effect, all tobacco products in Mongolia technically could be called illegal.15

Six countries introduced a high level of enforcement with the prohibition of the illegal trade, sixteen a moderate level, and one country a low level. New Zealand has put in place a high level of enforcement due to a comprehensive customs regime. Border security in New Zealand is an effective mechanism to control unregulated trade. Seizures of tobacco are minimal. The customs service contributes to the development of the national drug policy (of which tobacco is an identified issue).16 In Kenya, a country with moderate enforcement, the lack of distinctive marks makes it difficult to identify the smuggled packets.17 Another specific concern with enforcement in more than one country is the involvement of the tobacco industry in the control of smuggling. Peru, for instance, has only a moderate level

of enforcement and is vulnerable to tobacco industry participation in the fight against smuggling.18 Canada, also a country with a moderate level of enforcement, has a problem with illegal unlicensed cigarette manufacturers located in First Nations territories. There is a thriving market in contraband tobacco products transported from these territories into other communities by organized criminals, particularly in Ontario and Quebec.19

Discussion

The illicit tobacco trade is a problem in most countries around the world. Industry participation in the fight against smuggling in some countries might be a worrying trend. Under article 5.3, parties agree that “in setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law.” The FCTC excludes the involvement of the tobacco industry because the industry has fought for many years to undermine tobacco control, as industry documents uncovered through litigation in the USA have revealed.20 Estimates on the illicit trade are not available in all countries and are often provided by the tobacco industry. However despite these challenges, progress has been made in the markings of tobacco products. For instance, statements have been introduced on packages, such as: “sales only allowed in” in line with article 15.2 of the FCTC. Article 15.2b of the WHO Framework Convention requires that parties should “consider, as appropriate, developing a practical tracking and tracing regime that would further secure the distribution system and assist in the investigation of illicit trade.” Tracking, and its variants, refers to the ability of competent authorities to systematically monitor the movement of tobacco products from the place of manufacture, through the distribution chain, to the intended market of retail sale, making sure all relevant duties and taxes have been paid. Tracing, and its variants, refers to the ability of competent authorities, on the occasion of an audit or a seizure of a genuine product, to recreate the route taken by a tobacco product from the place of manufacture, through the distribution chain, to the point

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where the product has been diverted into illegal trade channels.21 A tracking system would allow authorities to monitor the movement of tobacco products around the world in order to avoid their diversion into illegal markets. The ability for authorities to follow the products is key to identify the point of diversion and hold those who are responsible accountable.

Illicit trade is a problem not only for parties with illicit tobacco products entering their territory but also for parties with illicit tobacco products emanating from or passing through their territory, and, if such smuggling is not adequately addressed, it may become a problem for many parties that currently have little or no illicit tobacco products either entering or leaving their territory. A protocol to the FCTC is necessary because the elimination of illicit trade requires the implementation

of a comprehensive system of international cooperation, such as tracking and tracing, which includes obligations and measures additional to those specified in article 15.

Recommendations

Based on the experience of combating illicit trade, parties should:1. Undertake reliable and independent studies

on the extent of the illegal tobacco trade.2. Introduce a tracking and tracing system to

enable products to be tracked and traced through the supply chain so the point of diversion into the smuggled market can be determined.

3. Using article 15 of the FCTC as a first step to combat smuggling, develop a more detailed protocol for a successful elimination of illicit trade in tobacco.

Notes1. Merriman, D., Yurekli, A., & Chaloupka, F. How big is the worldwide cigarette smuggling problem? In P. Jha & F.

Chaloupka (Eds.). Tobacco control in developing countries (pp. 365-392). New York: Oxford University Press, 2000.2. How big was the illicit tobacco trade problem in 2006? Framework Convention Alliance (FCA). Paper prepared for the

2nd session of the Conference of the Parties to the WHO FCTC, 30 June to 6 July 2007, Bangkok. Available at: http://www.fctc/org/documents/HowBigWasthe IllicitTobaccoTradeProblem_2006_English.pdf

3. Ibid.4. Joossens, L. Combatting the illegal tobacco trade from a public health perspective. Presentation at the first meeting of

the WHO expert committee on the illicit tobacco trade, Geneva, September 2006.5. Ibid.6. Personal communication from M. Asowa, team leader of the excise duty department of Customs, Mauritius, 3 April

2007. 7. State Specialized Inspection Agency. The report on nation-wide inspection on implementation of the law on tobacco

control. Ulaanbaatar: September 2006; p. 5.8. Australian National Audit Office. Audit Report No. 33 2005-06. Performance Audit. Administration of Petroleum and

Tobacco Excise Collections: Follow-up Audit Australian Taxation Office. Commonwealth of Australia, 2006. 9. Subuctageen, A. Illegal tobacco trade in Pakistan. Presentation at the first meeting of the WHO expert committee on

the illicit tobacco trade, Geneva, September 2006.10. Thailand, Announcement no. 12, Ministry of Public Health, 2006; 1966 Tobacco Act.11. Excise Act, 1901 (Cth) and the Customs Act, 1901 (Cth), Explanatory Memoranda, 2000. Australia.12. Law of Mongolia on Tobacco Control, article 7, 1 July 2005; Law of Mongolia on Excise Tax Stamp, article 5, 17

November 2000; Law of Mongolia on Licensing Business Activities, articles 15 & 16, 1 February 2001.13. Association of Mongolian Public Health Professionals. Assessment of the conformity of national policies with the

Framework Convention on Tobacco Control in Mongolia. Ulaanbaatar: Association of Mongolian Public Health Professionals, 2006; p. 8.

14. State Specialized Inspection Agency. The report on nation-wide inspection on implementation of the law on tobacco control. Ulaanbaatar: September 2006; pp. 2-3.

15. Personal communication from K. Chultem, Adventist Development and Relief Agency (ADRA) Mongolia, and T. Baljinnyam, Children, Youth, and Family Association, 31 March 2007.

16. New Zealand Customs Service. Annual Report 2005-2006. Available at: http://www.customs.govt.nz/NR/rdonlyres/B859FD1E-74D4-44AA-B9E0-C304C10AEE47/0/AnnualReport2006web.pdf

17. Personal communication from A. Ogwell, Oral and Craniofacial Research Associates, Kenya, 4 April 2007.18. Personal communication from C.F. Alburqueque, Comisión Nacional Permanente de Lucha Antitabaquica (COLAT),

Peru, 4 April 2007.19. Personal communication from M. DeRosenroll, Canadian Cancer Society, 23 March 2007.20. Tobacco company strategies to undermine tobacco control activities at the World Health Organization. Report of the

Committee of Experts on Tobacco Industry Documents, July 2000. Available at: http://www.who.int/tobacco/en/who_inquiry.pdf

21. World Health Organization. Elaboration of a template for a protocol on illicit trade in tobacco products. Conference of the Parties to the WHO Framework Convention on Tobacco Control, 2nd session, provisional agenda item 5.4.1, A/FCTC/COP/2/9, 19 April 2007. Available at: http://www.who.int/gb/fctc/PDF/cop2/FCTC_COP2_9-en.pdf

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Tobacco products are unusual in that, unlike other consumer products, very little is known about what manufacturers put into them and what constituents people are exposed to when using them. The manufacturers have guarded this knowledge fiercely, claiming trade secrecy. This is unsatisfactory, given the harm caused by tobacco use and particularly because we do know that some products, most notably cigarettes, are sophisticated and highly engineered devices designed to deliver nicotine very efficiently to the human body.

The Framework Convention on Tobacco Control aims to fill this regulatory vacuum by enabling regulators and the public to acquire accurate knowledge about tobacco products. Regulators will then be able to put in place measures that attempt to limit the harm of the products. However, the public health impact of implementing tobacco product regulations is, as yet, unclear. Although the status quo is unsatisfactory, there is an opportunity cost involved in implementing these articles. Doing so will consume resources and capacity which will then not be spent on other articles that have a much clearer public health impact.

Provisions of the FCTC that Address Tobacco Product Regulation – Articles 9 and 10

Article 9 concerns the testing, measurement, and regulation of the contents and emissions of tobacco products. Under this article, the Conference of the Parties (COP) is obliged, in consultation with competent international bodies, to propose guidelines for (1) testing and measuring the contents and emissions

of tobacco products, and (2) the regulation of these contents and emissions. Each party is required, where approved by competent national authorities, to adopt and implement effective legislative, executive, and administrative or other measures for such testing and measuring and regulation. Article 10 concerns disclosure of information about the contents and emissions of tobacco products to government and the public. Under this article, each party is required, in accordance with its national law, to adopt and implement effective legislative, executive, administrative, or other measures requiring manufacturers and importers of tobacco products to disclose information to governmental authorities about the contents and emissions of tobacco products. Each party is also required to adopt and implement effective measures for public disclosure of information about toxic constituents and emissions of tobacco products. At its first session, the COP requested the convention secretariat to initiate work on guidelines for the implementation of article 9, with the highest priority being given to the first phase of the article (i.e., testing and measuring of the contents and emissions of tobacco products).1 Because they are the most commonly used form of tobacco, cigarettes were to be the initial focus. The working group set up to develop these guidelines has produced a progress report for the second session of the COP.2 The progress report gives an update on work done thus far and proposes an outline for future work.

CHAPTER 8 OTHER FRAMEWORK CONVENTION ON TOBACCO CONTROL (FCTC) INITIATIVES

This chapter briefly addresses several FCTC articles. The 2007 FCA FCTC Monitor collected only basic data on these issues from each country, with the intention that further details on such topics may be included in subsequent editions of the FCA FCTC Monitor. The articles discussed here are: article 9 (regulation of the contents of tobacco products), article 10 (regulation of tobacco product disclosures), article 12 (education, communication, training, and public awareness), article 16 (sales to and by minors), article 20 (research, surveillance, and exchange of information), article 22 (cooperation in the scientific, technical, and legal fields and provision of related expertise), and article 26 (financial resources). Descriptions of the provisions of these articles, along with findings from the 2007 FCA FCTC Monitor and recommendations from authors, are included in each section.

TOBACCO PRODUCT REGULATIONAnn McNeill

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National Systems for Tobacco Product Regulation

Countries participating in the 2007 FCA FCTC Monitor reported on two aspects of articles 9 and 10: testing and measuring contents and emissions (article 9) and disclosure to governmental authorities about the contents and emissions of tobacco products (article 10). Of the 27 countries participating in the 2007 FCA FCTC Monitor, 11 data collectors report that their respective countries require measurement and testing of tobacco product contents and emissions (table 8.1). Data collectors from 12 countries report adopting measures requiring disclosure to governments (table 8.2). Data collectors from nine countries (Armenia, Canada, Hungary, Iceland, Mongolia, New Zealand, Norway, Slovakia, and Sri Lanka) report that their governments have adopted both sets of measures (i.e., testing and measuring and disclosure). Most of the high-income participating countries are taking some action with respect to articles 9 and 10 and some low- and middle-income countries are also taking action or planning to do so in the near future (India, Mauritius, Palau, Peru, and Kenya). Most countries in the European region have measures in place, largely because of the European products directive, which requires disclosure of some product attributes (ingredients and machine-based tar, nicotine, and carbon monoxide yields).3

However, on closer examination of the adopted

measures, it is clear that in most countries they are inadequate and piecemeal. Among the participating countries, Canada’s measures appear to be the most comprehensive. Canada has legislation requiring comprehensive disclosure covering most aspects of all tobacco products. However, Canada has not yet acted on this comprehensive regime and has not implemented any regulations other than governing the ignition propensity of cigarettes.

Other countries have measures, sometimes voluntary (such as Japan) which cover only one aspect of the product (e.g., machine emissions of only some constituents or ingredients) or have measures that apply to only some products on the market (e.g., those imported rather than manufactured locally). Although public disclosure was not surveyed, we are aware that in most countries, the public (which


With adopted measures (n=11)

Canada Jordan ArmeniaHungaryIcelandNorwaySlovakia

Sri Lanka JapanMongoliaNew Zealand

Without adopted measures (n=15)

KenyaMadagascarMauritius

PanamaPeruTrinidad & TobagoUruguayMexico

Pakistan BangladeshIndiaThailand

AustraliaFijiPalau

Unable to determine (n=1)

Ghana

Table 8.1. Countries with or without adopted measures that require testing and measuring contents and emissions of tobacco products, by WHO region

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With adopted measures (n=12)

Canada ArmeniaHungaryIcelandNorwaySlovakia

BangladeshSri LankaThailand

Australia*MongoliaNew Zealand

Without adopted measures (n=11)

KenyaMadagascarMauritius

PanamaPeruTrinidad & TobagoUruguay

Jordan India FijiPalau

Unable to determine (n=4)

Ghana Mexico Pakistan Japan

Table 8.2. Countries with or without adopted measures that require disclosure of contents and emissions of tobacco products to governments, by WHO region

* This is by a voluntary agreement rather than by regulation


includes relevant scientists) is not informed in any systematic way about the contents and emissions of tobacco products. Finally, many countries cite lack of skills and capacity as hindering their efforts to regulate the products.

Recommendations

Data from the 2007 FCA FCTC Monitor have shown that some parties are attempting to gain some knowledge of tobacco products on their markets. However, most of these measures are piecemeal, covering only certain aspects of the product and/or certain products on the market. Most rely on industry data and do not have the capacity to verify or validate this independently.

The FCA (with the support of Cancer Research UK) has produced three documents summarizing concerns about the implementation of articles 9 and 10.4,5,6 In the light of these concerns and the findings mentioned here, parties should take the following recommendations into account concerning the implementation of articles 9 and 10:

1. Prioritize implementation of articles that have a clear public health impact such as articles 6, 8, 11, 12, 13, 14, and 15.

2. Remove misleading product information from packaging such as quantitative emission yield information (article 11) before implementing articles 9 and 10.

3. Require the industry to disclose information about their products (article 10) and then verify the information supplied, rather than trying to assess all aspects of the products themselves.

4. Ensure that the industry also discloses design features such as filter ventilation and ignition propensity. Also include such features within the testing and measuring requirements of article 9 when implemented by parties.

5. Control through legislation any public disclosure of information to prevent the industry misleading the public about its products.

6. Ensure that all tobacco products are included when implementing measures under articles 9 and 10, and not just cigarettes.

The COP should take the following recommendations

into consideration when taking articles 9 and 10 forward:

7. Develop the rationale for product regulation. This should take account of the experience that countries have had in attempting to regulate tobacco products and the feasibility of doing so, in addition to scientific evidence. It should also examine approaches to reduce the toxicity of the product and approaches to reduce addictiveness.

8. Prioritize development and implementation of guidelines for article 11, which requires parties to ban misleading information about the risks of tobacco products from appearing on the packaging. These guidelines should include recommendations to remove misleading quantitative emissions yield information from packaging.

9. Develop guidelines on article 10 (disclosure to government and the public) parallel with developing guidelines for the first phase of article 9 (testing and measuring). This is because most parties are likely to require the industry to disclose content and/or emissions data about their products, and then try to verify this information pursuant to action they take under article 9.

10. Include the design of tobacco products explicitly within articles 9 and 10 and relevant guidelines. Regulating at least one aspect of design – the propensity of cigarettes to cause fires – is very likely to have a positive public health impact.

11. Do not put in place international guidelines to measure emissions until agreement has been reached on how best to do so. Validated standards for measuring contents do exist.

12. Do not put guidelines in place for regulating content or emissions until further research has been undertaken on the impact of such a strategy.

13. Identify funding mechanisms such as licensing tobacco products on a market, because implementing articles 9 and 10 will be costly.

14. Set up an international data repository that

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Although informed consent and basic consumer rights should inform people about the dangers of tobacco use, the World Bank has noted that “people’s knowledge of the health risks of smoking appears to be partial at best, especially in low- and middle-income countries where information about these hazards is limited.”7 Smokers tend to be even less aware of the risks of tobacco smoke to others,8 pesticide residue and additives in tobacco products,9 or adverse economic and environmental effects of tobacco production and consumption. Parties to the FCTC thus recognize the need to make the public sufficiently aware of tobacco control issues, so that they can make choices for their personal lives, influence others in their lives, and become engaged in tobacco control.

Provisions of the FCTC that Address Education, Communication, Training, and Public Awareness – Article 12

Educating the general public

Article 12 requires parties to the FCTC to use all available communication tools, as appropriate, to promote and strengthen public awareness of tobacco control issues. Towards this end, each party must adopt and implement “effective legislative, executive, administrative or other measures” to promote: “broad access to effective and comprehensive educational and public awareness programs on the health risks including the addictive characteristics of tobacco consumption and exposure to tobacco smoke” (article 12a); “public awareness about the health risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of cessation of tobacco use and

tobacco free lifestyles” (article 12b); and “public awareness of and access to information regarding the adverse health, economic, and environmental consequences of tobacco production and consumption (article 12f).

Article 12 underscores that tobacco is not just a personal health issue, but that it is a public health issue with economic and environmental consequences. As such, parties must ensure that the public is adequately educated about the spectrum of tobacco control issues, which may call for using traditional methods such as mandated lectures in national curricula, workshops, and symposia, as well as state-funded anti-tobacco mass-media campaigns using print, radio, television, and the Internet. Article 12 works in conjunction with other specific FCTC requirements such as prominent and effective health warnings (article 11) and comprehensive advertising bans (article 13) as measures to increase public awareness and reveal the truth about tobacco-related death and disease (which is often distorted by glamorous but deceptive tobacco advertisements).

In addition to educating their citizens about the health risks of tobacco consumption, article 12 requires parties to provide public access to information on the tobacco industry that is relevant to the objective of the FCTC (article 12c). This should include information with respect to tobacco farming and manufacturing (including use of pesticides and additives), advertising, promotions, sales, taxation, and, as recognized in the FCTC preamble, efforts by the tobacco industry to undermine or subvert tobacco control efforts. The use of

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will serve parties by analyzing and assessing country data and making international comparisons. This is important because there is a lack of appropriate skills and expertise to verify, assess, and analyze the product data.

15. Ensure guidelines for articles 9 and 10 cover

all tobacco products and not just cigarettes. Requirements for measuring, testing, and disclosure should be required of all tobacco products. For some products, measuring smoke emissions will of course not be necessary.

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such information in counter-advertising anti-tobacco campaigns has been shown to result in significant changes in anti-tobacco attitudes and beliefs and in reduced rates of smoking behaviour, especially among youth.10

Training of agencies, persons, and organizations

Towards the objective of promoting and strengthening public awareness of tobacco control issues, article 12 also requires the promotion of higher awareness among specialized groups. Parties are required to adopt and implement “effective legislative, executive, administrative or other measures” to promote: effective and appropriate training and awareness programs on tobacco control that are addressed to “persons such as health workers, community workers, social workers, media professionals, educators, decision-makers, administrators and other concerned persons” (article 12d); and awareness and participation of public and private agencies and NGOs that are not affiliated with the tobacco industry in developing and implementing intersectoral programs and strategies for tobacco control (article 12e). Again, the treaty is cognizant of the fact that the tobacco industry’s objectives are essentially the antithesis of tobacco control efforts and that, if given the opportunity, the tobacco industry will always work to undermine or subvert effective tobacco control policies and programs,11,12 including through planned collaboration with selected scientists,13 health professionals, and policy-makers, sophisticated public relations programs,14 and attacks on public health groups through front groups and third-party allies.15

The Real Score

Of the 27 countries participating in the 2007 FCA FCTC Monitor, data collectors from 23 countries report that people in their countries have access to educational and public awareness programs on the health risks of tobacco as well as public awareness about tobacco cessation. The extent of public awareness programs ranges from few and limited events (such as 31 May, World No Tobacco Day)16 and educational materials (brochures and stickers),17 to websites18 and various school-based curricula and programs,19 to nationwide mass media campaigns in

Australia, Canada, Iceland, New Zealand, and Norway.20 While some of these public awareness programs are stipulated in national law (Mongolia and Peru; see text box on “Article 12 translated into Mongolian law”)21 or in a national tobacco control program (Armenia, Canada, Fiji, New Zealand, Palau, Sri Lanka, Thailand, Trinidad and Tobago, and Uruguay),22 many initiatives are led by subnational governments and NGOs,23 and, in Sri Lanka, there could be better coordination among the different groups.24 The data collector from Fiji reports that there is “sufficient knowledge” on health risks among its communities,25 while Thailand’s success in its more than 20-year-long campaign is reflected in the generally negative attitude of the public towards tobacco use.26 However, data collectors from many countries, including Australia and Canada, underscore the existing inadequate levels of funding for public awareness programs.27 Data collectors from two countries, Bangladesh and India, report having no government-initiated educational or public awareness programs on either the health risks of tobacco or the benefits

Article 12 translated into Mongolian law

Article 4 of the Law of Mongolia on Tobacco Control (LMTC) states that one of the guiding principles of Mongolia’s state policy on tobacco control was “to increase the access…to scientific and practical information, training and advertising on negative health…consequences of tobacco consumption and passive smoking.” The legislation provides for establishing the Health Promotion Fund to finance activities on tobacco control, including “training, advertising and disseminating information on harmful effects of tobacco” (Paragraph 10.5 of LMTC).

The National Program on Prevention and Control of Non-Communicable Diseases (2005) also calls for all formal and informal educational curricula to include essential information on health risks of tobacco by 2009. It also calls for development of information, education and communications materials, of training programs, manuals, guidelines and recommendations on how to understand and practice a tobacco-free lifestyle. Those materials were to reflect the age, sex, educational background and occupation of target groups. The Program also schedules by 2012 to develop and implement specific recommendations on how to organize and conduct tobacco-free public actions, events and various competitions with status of “Tobacco-Free Youth”, “Tobacco-Free Sports”, “Tobacco-Free Performance Show” etc.

The Law of Mongolia on Tobacco Control, 1 July 2005The National Program on Prevention and Control of Non-Communicable Diseases, 14 December 2005.

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of tobacco cessation.28 However, India’s 13 cessation clinics are supported by the World Health Organization (as opposed to Mexico’s over 200 mainly public cessation clinics).29 In Ghana, some organizations undertake small-scale public awareness programs. It could not be determined if such programs exist in Japan.

Public access to information about the tobacco industry, however, is severely inadequate, with data collectors from only seven countries (Australia, Canada, Fiji, Iceland, Jordan, Palau, and Slovakia) reporting such access; even then, Iceland, Jordan, and Slovakia report that their information is limited. A majority (17 countries) does not have access to any information about the tobacco industry; for example, industry information is considered privileged information in Sri Lanka and requires a court order for disclosure.30 Data collectors from Thailand, Japan, and Ghana were unable to determine whether there were measures to promote public information on the tobacco industry, although limited information from tobacco company websites is reported in Thailand.31

Twenty-one countries have training on tobacco control, but this is deemed “totally inadequate” (Sri Lanka), “limited” (Bangladesh and Jordan), “occasional” (Peru), “developed but…not started” (Kenya), and in many instances focused on physicians and health workers in tobacco cessation programs or other select groups usually already involved in tobacco control.32 Data collectors from four countries (Ghana, Hungary, Iceland, and Japan) could not determine if there was such training although there are implications that no such training exists.

Policy Recommendations

In order for the public to be sufficiently aware of and engaged in tobacco control issues so that they can make choices for their personal lives and influence others to live tobacco-free lifestyles, we recommend that:

1. Parties must legislate and implement public awareness programs covering the full range of public issues (health, economic, and environmental effects, including product disclosures) and using “all available means” to do so, as required by the FCTC. Adequate funding must also be provided to sustain these programs.

2. Parties must provide broad public access to information on tobacco farming and manufacturing (including use of pesticides and additives), advertising, promotions, sales, taxation, and all efforts by the tobacco industry to undermine or subvert tobacco control efforts, including pertinent information from internal tobacco industry documents.

3. Anti-tobacco counter-advertising campaigns should be implemented, as these have been shown to be effective means of educating the public, especially youth, who are the main targets of the tobacco industry.

4. Parties must prohibit the tobacco industry and its affiliates from participating in the development and implementation of tobacco control programs, as well as the drafting of tobacco control laws and policies.

5. In addition to traditional tobacco control groups (health professionals and teachers), special tobacco control training programs must be designed and provided to policy-makers, lawyers, economists, environmentalists, media people, and customs and police officials, who can be valuable partners in raising public awareness, as well as in program development and implementation.

6. Among parties, there must be international cooperation and information sharing of the best practices and lessons learned for both public awareness campaigns and specialized training.

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In recent years, efforts have increased in several countries to reduce the supply of cigarettes and other tobacco products to young people in the hope that reduced access will also reduce the number of youth who become addicted.33,34 Laws that prohibit the sale and supply of tobacco to youth also send an important message regarding the dangers of tobacco use, and thus, at the very least, serve as a form of risk communication.

While controlling sales to minors is crucial, banning sales of tobacco by minors is equally important because, other than being a form of child labour, underage vendors are one of the easiest means of access to tobacco, both for themselves and for other minors, especially in countries where sales of individual sticks are allowed.

Provisions of the FCTC that Address Sales to and by Minors – Article 16

No tobacco sales to minors

Parties are required by article 16 to adopt and implement effective measures to prohibit sales of tobacco products to persons under the legal age set by domestic or national law or age 18 (minors). These may include a number

of measures aimed at making tobacco as inaccessible to minors as possible: requiring prominent signs at points of sale about the prohibition of tobacco sales to minors and, in case of doubt, requesting buyers to show appropriate evidence of legal age (article 16.1a); banning the sale of tobacco products in any manner by which they are directly accessible, such as store shelves (article 16.1b); banning the manufacture and sale of sweets, snacks, toys, or any other objects in the form of tobacco products which appeal to minors (article 16.1c); and ensuring that tobacco-vending machines are not accessible to minors and do not promote the sale of tobacco products to minors (article 16.1d).

Additionally, all parties are required to “prohibit or promote the prohibition of the distribution of free tobacco products to the public and especially minors” (article 16.2) and “endeavour to prohibit the sale of cigarettes individually or in small packets which increase the affordability of such products to minors” (article 16.3).

Article 16.6 requires parties to adopt measures to ensure compliance with the obligations on sales of tobacco products to minors, “including penalties against sellers and distributors.” This places some of the responsibility on sellers and distributors to prevent access by minors to this harmful substance.

Enforcement of bans on tobacco sales to minors

Some data collectors emphasize the need for strong political will and persistence in order to achieve a high level of enforcement. In Hungary, for example, “the consumer protection agency regularly checks the sale to minors, [such that] the compliance of retailers…improved substantially in the last few years.”47 The Fiji Ministry of Health says that “investigations on offenders [are] underway, and…prosecutions have begun.”48

A number of other data collectors describe their countries’ challenges in enforcing the ban on tobacco sales to minors. For example, in Australia, “some states do test purchasing using minors; others do not.”49 In Canada, “despite the laws that prohibit supplying tobacco to young people, young people who want to get tobacco products are able to find them. The cost of effective enforcement of these laws would be very high, which is why the health community recommends that governments focus on other areas of tobacco control first.”50 And in Palau, “enforcement is very low.”51 In Mauritius, “there are more than 10,000 points of sale of cigarettes...in Mauritius that are impossible to control!”52 Similarly, in India “no vendor [has] ever [been] booked for selling tobacco to minors despite documented evidence to this effect. No identity card is ever checked before the purchase of tobacco products.”53 A 2006 report from Thailand indicates that 64 percent of local administrative officials found some retailers who violate the law on sales to minors.54

Free tobacco samples and smaller tobacco packs: how the tobacco industry exploits loopholes

India: “Restriction…of free samples apply only…with an intention to promote tobacco. Industry subvert[s] such attempts by calling such activities as research.”57

Canada: “Some tobacco companies are starting to work around this limitation by producing packages of 20 cigarettes that can be split into two smaller packages after…purchase.”58

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No tobacco sales by minors

As mentioned, prohibiting sales of tobacco by minors not only protects minors from the hazards of child labour but also curtails easy access to tobacco, particularly by the vendors themselves. Article 16.7 states that each party to the FCTC should adopt and implement effective measures to prohibit the sales of tobacco products by minors.

The Real Score

Out of 27 participating countries, only data collectors from Ghana and Kenya report that their countries do not prohibit sales of tobacco products to minors; however, in Ghana this measure is included in its currently proposed tobacco control bill. Twenty-five countries have declared tobacco sales to minors as illegal, many of them prior to the FCTC coming into force. Although 18 is the legal age in most countries, Sri Lanka and Japan have prohibited sales to those below age 21 and 20,35,36 respectively, while in Canada, seven provinces and territories have established a minimum age of 19.37 Australia’s laws banning sales to minors are at a subnational (state or territorial) level, rather than at the federal level.38

However, enforcement of this ban is exceptionally poor, being high in only three countries and low to non-existent in 15 of these countries (table 8.3). According to country surveys, including the Global Youth Tobacco Survey, in Mexico, Mongolia, Peru, Thailand, and Trinidad and Tobago,

between 28.3 and 79.6 percent of current youth smokers buy their cigarettes from a store, and between 60 and 92.4 percent of these youth are never refused purchase despite being underage.39

Countries were almost equally split (12=yes, 13=no, 2=unable to determine) on the question of whether the manufacturing and sales of tobacco-related sweets, snacks, and toys was banned. While 19 countries have banned free samples of tobacco products, six (India, Kenya, Mexico, Pakistan, Palau, and Trinidad and Tobago) have not. In Uruguay, despite such a ban, “there is no control of it,”55 while in Panama, such promotions are authorized for exclusively adult events.56 Data collectors from Japan and Ghana could not determine if free samples are prohibited in their countries.


High*(n=3)

HungaryNorway

Fiji

Moderate*(n=9)

Madagascar CanadaPanama

Jordan Iceland Sri Lanka AustraliaJapanNew Zealand

Low or none*(n=15)

GhanaKenyaMauritius

MexicoPeruTrinidad & TobagoUruguay

Pakistan ArmeniaSlovakia

BangladeshIndiaThailand

MongoliaPalau

*Notes:High – Examples: Regular compliance checks by government;40 sanctions being imposed;41 few violations42 Moderate – Examples: Inconsistent monitoring;43 youth are able to obtain tobacco despite youth access laws;44 regular inspections but violators are rarely prosecuted45

Low or none – Examples: Many youths are able to buy tobacco from stores;39 no sanctions or age verification46

Table 8.3. Level of enforcement of ban on tobacco sales to minors, by WHO region


Yes (n=12)

CanadaMexicoPanamaPeruUruguay*

Jordan ArmeniaIcelandSlovakia

AustraliaMongoliaNew Zealand

No (n=15)

GhanaKenyaMadagascarMauritius

Trinidad & Tobago

Pakistan HungaryNorway*

BangladeshIndiaSri LankaThailand*

FijiJapanPalau

*Norway and Uruguay prohibit single stick sales but not small packets (minimum of 10 sticks for Norway). Thailand prohibits sales of small packets, but not single sticks.

Table 8.4. Prohibition of cigarette sales individually or in small packets, by WHO region

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Sadly, more than half (15) of the 27 countries allow sales of individual cigarettes and in packs of less than 20 sticks, the majority of which are in the African and Southeast Asian regions (table 8.4). Unfortunate also is the fact that in Mexico, although “it is forbidden to sell by unit [there is] very bad enforcement and compliance, especially close to schools and in street commerce and small grocery stores.”59 This once again clearly demonstrates that although legislation is vital, enforcement of the law is equally necessary.

It is rather regrettable that the FCTC offers some weak language (“promote the prohibition of the distribution of free tobacco products to the public and especially minors” and “endeavour to prohibit the sale of cigarettes individually or in small packets which increase the affordability of such products to minors”) as an option for parties when its intention is to keep this lethal product out of the hands of youths.

Policy Recommendations

Although a number of studies have found that reducing sales to minors contributes to a reduction in the prevalence of youth smoking, while others have not,60 the fact remains that more than a quarter of the world population is below 15 years of age,61 and it is thus imperative that smoking among young people be kept to a minimum. Ironically, at least one report suggests that prohibiting sales to minors and restricting sales to adults may actually reinforce the concept of the “adult decision” to smoke that is widely promoted by the tobacco

industry through its ineffective youth smoking-prevention programs; however, it may become more effective if it is properly implemented with other measures to curb youth smoking, such as “smoke-free workplaces and homes, [higher] taxes, media campaigns, and second-hand smoke messages.”62

We thus recommend:1. Parties must enforce strong sanctions

(including imposing heavy fines and suspending business licences) on violators of the ban on sales to minors, including through vending machines and the Internet.

2. As it is impossible to control non-commercial sources of tobacco (such as adults, older youths, and theft), parties should consider increasing the legal age for purchasing tobacco to prevent legal-age youths from buying tobacco for underage youths.

3. Parties should implement other measures proven to be more effective at curbing youth smoking: higher taxes, comprehensive advertising bans, smoke-free places, media campaigns, and messages about the dangers of second-hand smoke.

4. Parties should use stronger language in their own national legislation (rather than “promote the prohibition,” “endeavour to prohibit,” or “should” instead of “shall”) to prohibit outright (a) the use of tobacco-vending machines (b) all free tobacco product samples to the public, (c) sales of cigarettes individually or in packs of less than 20 sticks, and (d) sales of tobacco products by minors.

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Research is essential to identify and evaluate effective interventions for tobacco control and to support evidence-based public health policy. The findings of tobacco control research studies provide policy-makers with the evidence base necessary to implement and defend effective policies and to choose which policy may be most adequate.63 Given dynamic changes in social and political norms and in industry strategies that affect people’s tobacco use and exposure to tobacco smoke, the evaluation of current tobacco control strategies and the identification of more effective strategies is a permanent need that requires continuous and high-quality research. Surveillance refers to the systematic ongoing collection, analysis, and interpretation of health data that is essential to the planning, implementation, and evaluation of public health practice, including timely dissemination to those responsible for prevention and control (adapted from WHO and CDC definitions as included in Last 2001).64 Surveillance of the distribution and determinants of tobacco use, exposure to tobacco smoke, tobacco-related health effects, and tobacco control activities are essential components of tobacco control programs.65 The information gathered is useful to guide the implementation and readjustment of interventions and policy decisions. Surveillance is also useful to identify research needs. As tobacco control programs and policies are implemented worldwide, the international community requires a systematic evaluation of the impact of these activities in tobacco use, exposure to tobacco smoke, and related health effects. Timely and effective communication of surveillance data and research findings depends upon the exchange of information at local, national, and international levels.

Provisions of the FCTC that Address Research, Surveillance, and Exchange of Information – Article 20

Under article 20, parties to the FCTC accept a range of obligations with respect to research, surveillance, and exchange of information regarding tobacco and tobacco control, and

related activities including cooperation and provision of training and support.

Research

The parties are required to develop and promote national research and to coordinate research programs at the regional and international levels in the field of tobacco control (article 20.1). Towards this end, each party must initiate and cooperate in, directly or through competent international and regional intergovernmental organizations and other bodies, the conduct of research and scientific assessments, and in so doing promote and encourage research that addresses the determinants and consequences of tobacco consumption and exposure to tobacco smoke, as well as research for identification of alternative crops (article 20.1a).

Training and support

In order to develop and promote national research, each party is required to promote and strengthen training and support for all those engaged in tobacco control activities (article 20.1b).

Surveillance

The states are required to establish programs for national, regional, and global surveillance of the magnitude, patterns, determinants, and consequences of tobacco consumption and exposure to tobacco smoke. Towards this end, the parties should integrate tobacco surveillance programs into national, regional, and global health surveillance programs so that data are comparable and can be analyzed at the regional and international levels as appropriate (article 20.2). Each party shall endeavour to establish progressively a national system for the epidemiological surveillance of tobacco consumption and related social, economic, and health indicators (article 20.3a).

Exchange of information

The parties are required to promote and facilitate the exchange of publicly available

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RESEARCH, SURVEILLANCE, AND EXCHANGE OF INFORMATIONAna Navas-Acien 65


scientific, technical, socio-economic, commercial, and legal information, as well as information regarding practices of the tobacco industry and the cultivation of tobacco (article 20.4). In so doing, parties must address and take into account the special needs of developing-country parties and parties with economies in transition.

National Systems for Tobacco Epidemiologic Surveillance

Of the 27 countries participating in the 2007 FCA FCTC Monitor, 15 have a national system for epidemiologic surveillance of tobacco consumption and related social, economic, and health indicators (table 8.5). Among countries with a national system, data collectors from 12 countries report having an updated database of the data collected and 10 characterize the current level of tobacco surveillance activities as adequate or very adequate.

While all high-income participating countries have a national system for tobacco surveillance (Australia, Canada, Iceland, Japan, New Zealand, and Norway), most low-income participating countries (Bangladesh, Ghana, India, Madagascar, Mongolia, and Pakistan) and many lower-middle- and upper-middle-income participating countries (Armenia, Fiji, Panama, Trinidad and Tobago, and Uruguay) have no national system. In Kenya, the only low-income country with a national surveillance system for tobacco control, surveillance is not conducted on a regular basis but on an ad hoc basis. Lower-middle- and upper-middle-income countries with a national surveillance system are Hungary, Jordan, Mexico, Peru, Slovakia, Sri Lanka, and Thailand. In Armenia, the national surveillance system is in the process

of development. In several countries – including India, Mongolia, Pakistan, and Panama – a structured and consistent surveillance system is still lacking, despite collecting some tobacco-related indicators. In Mongolia, for instance, although

an integrated surveillance system was called for in 2005 by the national program on prevention and control of non-communicable diseases, the system was not yet in place as of March 2007 (see box at right: Challenges for national tobacco surveillance).

Data collectors from several countries, including Armenia, highlight that national funds for tobacco control surveillance are insufficient and that existing national surveillance depends on international funding.

Regarding the adequacy of the surveillance system, most data collectors from high-income countries (Australia, Canada, Iceland, New Zealand, and Norway) and some lower-middle- and upper-middle-income countries (Hungary, Jordan, Mexico, Peru, and Thailand) characterize

Challenges for national tobacco surveillance

In Armenia, “the existing tobacco-related surveillance heavily depends on external funding (WHO, international agencies, and donor organizations).”67

In Australia, “surveillance is adequate and covers a number of demographics, however, population groups such as Indigenous Australians or those from some culturally and linguistically diverse groups who have very high smoking rates are not adequately represented.”68

“No such program or initiative exists” in India.69

In Mongolia, “the national program on prevention and control of non-communicable diseases (December 2005) called for the Ministry of Health (MOH) to establish an integrated system of surveillance of risk factors for non-communicable diseases, including tobacco consumption. As of March 2007, the national body responsible for surveillance of tobacco consumption has not yet been appointed.”70

“We would need assistance [in Palau] to gather information and data that demonstrate the economic impact (cost-benefit analysis) of tobacco use.”71

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Yes (n=15)

Kenya CanadaMexicoPeru

Jordan HungaryIcelandNorwaySlovakia

Sri LankaThailand

AustraliaJapanNew ZealandPalau

No (n=12)

GhanaMadagascarMauritius

PanamaTrinidad & TobagoUruguay

Pakistan Armenia BangladeshIndia

FijiMongolia

Table 8.5. Countries with/without a national system for tobacco epidemiologic surveillance, by WHO region66


Cooperation across countries and disciplines is essential to conduct research and surveillance in the field of tobacco control, as well as to implement the policies needed to fulfill the requirements of the FCTC. The FCTC, developed in response to the global impact of the tobacco epidemic, acknowledges the importance of international factors (e.g., cross-border effects and global marketing) in spreading tobacco use and exposure to tobacco smoke. To counteract these international factors, and to allow for a comparable core of data to track the effective implementation of the FCTC and the evolution of the tobacco epidemic, countries need scientific, technical, and legal cooperation internationally. Within countries, cooperation is also needed across disciplines, and support must allow for transfer of expertise, promotion of research, material, and logistics, as well as financial support.

Provisions of the FCTC that Address Cooperation in the Scientific, Technical, and Legal Fields and Provision of Related Expertise and Financial Support

Article 22 of the FCTC promotes cooperation between parties in the scientific, technical, and legal fields and in the provision of related expertise. Parties are required to cooperate either directly or via international bodies to fulfill the obligations arising from the FCTC, taking into account the needs of developing-country parties and parties with economies in transition (article 22.1). Such cooperation “shall promote the transfer of technical, scientific and legal expertise and technology, as mutually agreed, to establish and strengthen national tobacco control strategies, plans and programmes.” This can be achieved through a number of different mechanisms, including facilitation of development, transfer, and acquisition of technology, skills and capacities; provision of material support; provision of scientific, legal, and other expertise; and promotion of research.

COOPERATION IN THE SCIENTIFIC, TECHNICAL, AND LEGAL FIELDS AND PROVISION OF RELATED EXPERTISE AND FINANCIAL SUPPORTAna Navas-Acien

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the current level of tobacco surveillance activities as adequate or very adequate. In Mexico, an upper-middle-income country with an adequate surveillance system, there are several surveys tracking the tobacco epidemic, including the National Survey on Addiction, the National Health Survey, the National Survey of Income and Expenditure in Households and the Global Youth Tobacco Survey.66 A major concern noted in countries with adequate national tobacco surveillance is that vulnerable populations are not always adequately represented.

Summary and Recommendations for Tobacco Control Surveillance

Overall, many low- and middle-income countries lack technical expertise, funding, and/or

political support to set up adequate, consistent, and structured tobacco-surveillance systems. The establishment of core indicators for tobacco control and of adequate monitoring systems remains a priority in many countries worldwide. In addition to fulfilling article 20 of the FCTC, developing and promoting national research surveillance will be essential in evaluating the tobacco epidemic and monitoring the progress of tobacco control activities around the world. In countries with adequate surveillance systems, data collected in high-risk populations remain a priority for tobacco control research and surveillance.

67


Under article 26, parties to the FCTC recognize the important role that financial resources play in achieving the objective of the convention. Each party is required to provide financial support in respect of its national activities intended to achieve the objective of the convention (article 26.2). Parties are also required to promote “the utilization of bilateral, regional, subregional and other multilateral channels to provide funding for the development and strengthening of multisectoral comprehensive tobacco control programmes of developing country parties and parties with economies in transition” (article 26.3).

Technical or Other Assistance from International Bodies

Among the 27 countries participating in the 2007 FCA FCTC Monitor, 19 data collectors report that their countries have received technical or other assistance from international bodies to strengthen their capacity to fulfill the obligations of the convention (table 8.6). The reported reasons for not receiving international assistance are diverse and may also reflect differences in the way that data collectors interpreted the issue of international assistance for tobacco control. In Mauritius, for instance, while WHO provides support to the government for non-communicable diseases, no specific sum is earmarked for tobacco control or FCTC implementation.72 In New Zealand, on the other hand, the majority of the legislation was already in place prior to FCTC ratification. Because national support and technical expertise is limited in many low- and middle-income countries, the amount and constancy of international support plays a key role in tobacco research and surveillance there.

Some international bodies that provide technical assistance include: the American Cancer Society, Canadian Tobacco Control Forum, Canadian International Development Agency, Centers for Disease Control and Prevention, European Network for Smoking Prevention,

European Union, Framework Convention Alliance, Institute for Global Tobacco Control, and the World Health Organization (including the Pan American Health Organization). Some examples of multi-country projects highlighted by the data collectors that have been supported by international agencies and have provided relevant and comparable data for tobacco surveillance include the Global Youth Tobacco Survey (GYTS)73,74 and multi-country projects assessing second-hand tobacco smoke in public places in Europe and Latin America.75,76

Summary and Recommendations for International Assistance

International bodies play an important role in supporting tobacco control surveillance activities in many countries, particularly in low- and middle-income countries. So far, international efforts have included technical, material, and financial support to conduct research in tobacco control. International efforts, however, vary widely from country to country. Frequently, these efforts are ad hoc and dependant on the availability of resources and the interest of donors. Given the need to develop sustainable national surveillance systems in many low- and middle-income countries, international efforts remain critical and should increase in some countries. In order to support ongoing and systematic collection of tobacco control data that is relevant at the country level, harmonization of international and national efforts is essential.

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Yes (n=19)

GhanaKenyaMadagascar

MexicoPanamaPeruTrinidad & Tobago

JordanPakistan

ArmeniaIcelandNorwaySlovakia

BangladeshIndiaSri LankaThailand

FijiMongolia

No (n=8)

Mauritius CanadaUruguay

Hungary AustraliaJapanNew ZealandPalau

Table 8.6. Countries receiving technical or other assistance from international bodies for tobacco control research, by WHO region

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Support for National Tobacco Control Programs: Transfer of Expertise, Promotion of Research, Material and Logistic Support, Financial Support

Transfer of expertise

Twelve data collectors indicate the promotion of transfer of technical, scientific, and legal expertise to strengthen national tobacco control programs (Figure 8.1). Some examples of transfer of expertise include: (1) The one-week training course in tobacco control offered by the National Institute of Public Health of Mexico to Latin American personnel from the State Councils against Additions;77 (2) Thailand’s international advocacy role in promoting adequate resources for tobacco control; and (3) Uruguay’s shared experiences in smoke-free environments and warning labels at a regional level.

Promotion of research

Seventeen data collectors indicate that their countries promote research to support tobacco control programs (figure 8.1). Initiatives to promote research for tobacco control differ across countries. In Norway, much of the tobacco control research is coordinated by the Norwegian Institute for Alcohol and Drug Research.78 In Thailand, the Thai Health Promotion Foundation supported the establishment of the Tobacco Control Research and Knowledge Center in 2005 to conduct policy-related research. After the first year, the

centre was able to effectively use 89 percent of its planned budget for that first year (about 30 million THB, or just over 900,000 USD).

In countries such as Bangladesh, Hungary, and Mauritius, government support for tobacco control research is minimal and in other countries such as Ghana, India, and Palau, research is supported mostly from international bodies. Palau hopes to generate some local funding for programs with new legislation for taxation.

Material and logistic support

Data collectors from 12 participating countries report that their countries provide the necessary material and logistical support for tobacco control programs, while data collectors from 10 countries report that their countries do not. In many countries, material and logistic support at the government level is lacking or limited. For example, in India, no resource and support for tobacco control initiatives exist at the ministry of health level. In small countries such as Fiji and Palau, material support changes with the availability of resources and is dependent on foreign grants and programs. Brochures, publications, lectures, and support for school programs are provided by the government in several countries (e.g., Hungary, Iceland, Jordan, Thailand), although sometimes with significant delays. In Australia, as in many other countries, NGOs contribute with logistical and material support for tobacco control. Provisions in New Zealand and Slovakia are made through the national budget to government organizations (e.g., the Health Sponsorship Council in New Zealand) and via contracts or grants to NGOs.

Sufficient financial support

The data indicate that 4 countries provide sufficient financial support for national tobacco control programs and 21 countries provide insufficient financial support (figure 8.1). Of the 21 countries indicating insufficient financial support, 13 have no national financial support for tobacco control, 7 have some support but it is not considered sufficient, and 1 country discusses the lack of support for NGOs in tobacco control. Given the nature of the question, the consideration of financial support

Figure 8.1. Number of countries indicating they promote or provide the following type of support to strengthen national tobacco control programs

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as sufficient or insufficient may be open to interpretation and could vary depending on the country level of support for other health activities, economic resources, and expectations.

Countries where data collectors reported sufficient financial support include Armenia, Iceland, New Zealand, and Thailand. In Iceland, according to the Tobacco control act no. 6/2002, 0.9 percent of all sold tobacco is to be used for tobacco control and tobacco prevention.79 In New Zealand, the government annually receives over NZD$1B (over 752 million USD) in tobacco tax and allocates only NZD$38M (28.6 million USD) for tobacco control. This allocation can be qualified as sufficient for the services currently provided. From the NGO’s perspective, however, additional funding is needed for multimedia campaigns, for increased cessation services, and for other services. In Thailand, although it is still limited, funding of control efforts has increased with a 2 percent tax on tobacco and alcohol being directed to the Thai Health Promotion Foundation. Among other activities, this increased funding in Thailand has supported additional research for tobacco control. In countries such as Australia, Japan, and Norway, financial support for tobacco control is characterized as insufficient compared to guidelines established by the Centers for Disease Control and Prevention (CDC), to other health policies, and to other European countries, respectively. In Bangladesh, Ghana, Panama, and several other low- and middle-income countries, financial resources are scant.

Summary and Recommendations for Transfer of Expertise, Promotion of Research, Material and Logistic Support, Financial Support

From the data collected in the 2007 FCA FCTC Monitor, it is possible to infer that current levels of financial support for tobacco control must increase if the goals to strengthen tobacco control programs and to maintain and/or develop systematic surveillance systems are to be met. By providing sufficient financial support and assuring its effective application, technical, logistical, and material support is expected to increase, leading to more research and to new strategies for improving surveillance systems and tobacco control activities. Transfer of expertise among countries, through bilateral and multilateral collaborations, remains an essential strategy to learn from best practices.

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Insufficient financial support for tobacco control programs

“Australia has a national tobacco strategy to which no funding is allocated. Specific projects are sometimes funded by the federal government, but these are ad hoc and time limited … All of this funding combined is at a level far lower than that recommended by the CDC in their guidelines for Best Practice for Comprehensive Tobacco Control Programs.”80

In Bangladesh, “[Financial support] depends more on external financial support especially WHO.”

In Canada, “health organizations consider the level of funding for tobacco control by federal and provincial governments to be inadequate.”

There is “no specific budget line for tobacco control activities” in Ghana.

In Japan there is “only a small amount (400,000 dollars in 2007) of money provided for tobacco control compared to other policies.”

“Will there ever be enough financial support for tobacco control activities? … Norway provides less financial support to tobacco control activities compared with other European countries.”

In Panama “Up-to-date the available resources in the state [national] budget … are insignificant, if not null … To date there does not exist a regulation which allows the orientation of the resources collected by the taxes of tobacco products to the development of promotion and prevention actions.”

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Notes1. World Health Organization. Conference of the Parties to the WHO Framework Convention on Tobacco Control. 1st

Session, List of decisions, A/FCTC/COP/1/DIV/8, 23 March 2006, Geneva. Available at: http://www.who.int/gb/fctc/PDF/cop1/FCTC_COP1_DIV8-en.pdf

2. World Health Organization. Conference of the Parties to the WHO Framework Convention on Tobacco Control. Elaboration of guidelines for implementation of the Convention. Decision FCTC/COP1(15). Article 9: Product regulation. 2nd session. A/FCTC/COP/2/8. Geneva, 26 April 2007.

3. The European Parliament and of the Council of the European Union. Directive 2001/37/EC of the European Parliament and of the Council of 5 June 2001 on the approximation of the laws, regulations, and administrative provisions of the member states concerning the manufacture, presentation and sale of tobacco products. Luxembourg, 2001.

4. Framework Convention Alliance (FCA). Framework Convention on Tobacco Control (FCTC): Developing effective product regulation under the FCTC. Cop-2 Briefing paper. Geneva: FCA, February 2006.

5. FCA. Developing effective product regulation under the FCTC. Briefing paper for tobacco regulation Kobe meeting. Available at: http://fctc.org/documents/FCA_tobacco_product_regulation_0606.pdf

6. FCA. Briefing for the meeting to develop guidelines for the implementation of the tobacco product regulation provisions of the WHO FCTC. Ottawa, October 2006.

7. Jha, P., & Chaloupka, F.J. Curbing the epidemic: Governments and the economics of tobacco control. Washington, DC: World Bank, 1999.

8. Nathan, R. Model legislation for tobacco control: A policy development and legislative drafting manual. Paris: International Union for Health Promotion and Education, 2004.

9. Chapman, S. Keep a low profile: Pesticide residue, additives, and freon use in Australian tobacco manufacturing. Tobacco Control 2003; 12 (Suppl. 3): 45–53.

10. Sly, D.F., Heald, G.R., & Ray, S. The Florida “truth” anti-tobacco media evaluation: Design, first year results, and implications for planning future state media evaluations. Tobacco Control 2001; 10: 9–15.

11. Chapman, S., & Carter, S.M. Avoid health warnings on all tobacco products for just as long as we can: A history of Australian tobacco industry efforts to avoid, delay and dilute health warnings on cigarettes. Tobacco Control 2003; 12 (Suppl. 3): 13–22.

12. Assunta, M., & Chapman, S. A mire of highly subjective and ineffective voluntary guidelines: Tobacco industry efforts to thwart tobacco control in Malaysia. Tobacco Control 2004; 13 (Suppl. 2): 43–50.

13. Tong, E.K., & Glantz, S.A. ARTIST (Asian regional tobacco industry scientist team): Philip Morris’ attempt to exert a scientific and regulatory agenda on Asia. Tobacco Control 2004; 13(Suppl. 2): 118–124.

14. Bornhäuser, A., McCarthy, J., & Glantz, S.A. German tobacco industry’s successful efforts to maintain scientific and political respectability to prevent regulation of second-hand smoke. Tobacco Control 2006; 15: e1.

15. Ibrahim, J.K., Tsoukalas, T.H., & Glantz, S.A. Public health foundations and the tobacco industry: Lessons from Minnesota. Tobacco Control 2004; 13: 228–236.

16. Republic of Mauritius. Cabinet decision, 12 May 2006 regarding World No Tobacco Day 2006. Retrieved 20 May 2007 from Republic of Mauritius website (via links to government, information & policies, to cabinet decisions by date): http://www.gov.mu ; Dosoruth, P. La douleur des non-fumeurs, Mauritius L’Express 31 May 2006. Retrieved 20 May 2007 from: http://www.lexpress.mu/display_search_result.php?news_id=65928.

17. Personal communication from M.D. Mohee, head of the prevention and education unit, Ministry of Health, Mauritius, 3 April 2007; personal communication from A. Ogwell, Oral and Craniofacial Research Associates, Kenya, 4 April 2007; Madagascar Annual Report of the National Office for Tobacco Control, 2006.

18. New Zealand Ministry of Health. Available at: http://www.moh.govt.nz/tobacco and http://www.quit.org.nz19. Personal communication from A. Ogwell, Oral and Craniofacial Research Associates, Kenya, 4 April 2007, based on

information from Kenya Ministry of Health; personal communication from O. Gunasekera, ADIC Sri Lanka, 26 March 2007, based on information from Sri Lanka Ministry of Health; Commemorative activities report of the National Day of Not Smoking and the International Day of Not Smoking, Years 2000- 2006, Coalición Panameña Contra el Tabaquismo (COPACET) Activities Report, October 2006; personal communication from T. Demjen, department head, National Institute for Health Development, Hungary, 15 March 2007.

20. Personal communication from: K. Lindorff, VicHealth Centre for Tobacco Control, Australia, 26 March 2007; M. DeRosenroll, Canadian Cancer Society, 23 March 2007, based on information from Physicians for a Smoke-Free Canada; V. Jensson, Public Health Institute of Iceland, 4 April 2007; S. Bradbrook, Te Reo Marama — Maori Smoke-Free Coalition, 26 March 2007, based on information from New Zealand Ministry of Health; B. Rosted, Norwegian Cancer Society, 12 March 2007, based on information from Norwegian Directorate for Health and Social Affairs.

21. Law of Mongolia on Tobacco Control 2005; Action Plan to Implement the National Program on Prevention and Control of Non-Communicable Diseases, 2005. Mongolia; Law 28705, 2006, Peru.

22. Government resolution 1630-N on approval of the State Tobacco Control Program and the list of priorities in tobacco control, September 2005, Armenia State National Tobacco Control Program; personal communication from: M. DeRosenroll, Canadian Cancer Society, 23 March 2007, based on information from Physicians for a Smoke-Free Canada; L. Ligabalavu, Fiji Ministry of Health, 25 March 2007; S. Bradbrook, Te Reo Marama — Maori Smokefree Coalition, 26 March 2007, based on information from New Zealand Ministry of Health; Palau Ministry of Health Tobacco Control Program; O. Gunasekera, ADIC Sri Lanka, 26 March 2007, based on information from Sri Lanka Ministry of Health; Discussion of the Tobacco Research Centre Working Group, 13 March 2007, Thailand; C. Alexis-Thomas, Coalition for Tobacco-Free Trinidad and Tobago, 26 March 2007; Uruguay Ministry of Health, national resources fund web page, Campaigns (“No me hagas humo” [Don’t make me smoke]), MOH and PAHO, run in 2005, available at http://www.msp.gub.uy and A million thanks campaign, MOH and PAHO, February to May 2006. Available at: http://www.fnr.gub.uy

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23. Personal communication from: K. Lindorff, VicHealth Centre for Tobacco Control, Australia, 26 March 2007; O. Gunasekera, ADIC Sri Lanka, 26 March 2007; Action of ViSa, L’Express (Mauritius). Retrieved from: http://www.lexpress.mu/display_search_result.php?news_id=66134 ; personal communication from Mr. Ochaba, Public Health Authority, Slovakia, 20 March 2007; Stop Smoking NGO, Slovakia, available at: http://www.stopfajceniu.sk ; Thailand Discussion of the Tobacco Research Centre Working Group, 13 March 2007.

24. Personal communication from O. Gunasekera, ADIC Sri Lanka, 26 March 2007, based on information from Sri Lanka National Federation on Smoking or Health.

25. Personal communication from L. Ligabalavu, Fiji Ministry of Health, 25 March 2007.26. Discussion of the Tobacco Research Centre Working Group, Thailand, 13 March 2007.27. Scollo M. Tobacco control: A blue chip investment in public health, VicHealth Centre for Tobacco Control, 2001;

personal communication from M. DeRosenroll, Canadian Cancer Society, 23 March 2007, based on information from Physicians for a Smoke-Free Canada.

28. Three Year Plan: National Policy and Plan of Action for Tobacco Control in Bangladesh, 2007-2010. Ministry of Health and Family Welfare. Bangladesh.

29. Personal communication from F.J. López Antuñano, Alianza Contra el Tabaco, A.C., Mexico 31 March 2007; Reddy, K.S., & Gupta, P.C. (Eds.). Report on tobacco control in India. New Delhi: Ministry of Health and Family Welfare & WHO, 2004; p. 247

30. National Authority on Tobacco and Alcohol Act, no. 27/2006. Sri Lanka.31. Discussion of the Tobacco Research Centre Working Group, Thailand, 13 March 2007.32. Personal communication from: Z. Alawneh, Land and Human to Advocate Progress (LHAP), Jordan, 4 April 2007,

based on information from Jordan Ministry of Health; C.F. Alburqueque, Comisión Nacional Permanente de Lucha Antitabaquica (COLAT), Peru, 4 April 2007, based on information from Ministry of Health; A. Ogwell, Oral and Craniofacial Research Associates, Kenya, 4 April 2007; S.M. Alam Tahin, WBB Trust (Work for a Better Bangladesh), and S. Ahmed, Bangladesh Anti-Tobacco Alliance (BATA) – 16 March 2007; M. Peiris, Jeewaka Foundation, 26 March 2007, based on information from Sri Lanka Ministry of Health; National Coordination Board for Tobacco Control (Slovakia); E. Bianco, Research Centre of the Tobacco Epidemic, Uruguay, 27 March 2007; State National Tobacco Control Program, Armenia; M.D. Mohee, head, prevention and education unit, Ministry of Health, Mauritius; F.J. López Antuñano, Alianza Contra el Tabaco, A.C, Mexico, 31 March 2007; M. Deowan Mohee, head, prevention and education unit, Ministry of Health, Mauritius, 3 April 2007; Peter Šťastný, Jana Potúčková, Stop fajčeniu, občianske združenie (Stop Smoking NGO), Slovakia, 20 March 2007.

33. Tilson, M. A critical analysis of youth access laws. Ottawa: Canadian Cancer Society, 2002.34. National Tobacco Information Online System (NATIONS). Country profiles. Retrieved from: http://apps.nccd.cdc.gov/

nations/nations/country_specific_indicators.asp35. National Authority on Tobacco and Alcohol Act, no. 27/2006. Sri Lanka.36. Prohibition of Minors Smoking Law, 1913. Japan.37. Personal communication from M. DeRosenroll, Canadian Cancer Society, 23 March 2007, based on information from

Canadian Cancer Society; Physicians for a Smoke-free Canada; section 8 of the 1997 federal Tobacco Act. Available at: http://www.canlii.org/ca/sta/t-11.5/

38. Quit Victoria and VicHealth Centre for Tobacco Control. National Smokefree Legislation, October 2005. Unpublished table. Australia.

39. Personal communication from C.F. Alburqueque, Comisión Nacional Permanente de Lucha Antitabaquica (COLAT), Peru, 4 April 2007. Based on survey to young people 2003; Global Youth Tobacco Survey (2005, Thailand; 2003, Mongolia; 2000, Trinidad and Tobago; 2003, Mexico); Sirichotiratana., N. et al. Linking global youth survey (GYTS) data to the WHO framework convention on tobacco control: The case for Thailand. 2005; Interview with G. Tsetsegdary, Policy and activities of the Ministry of Health on Tobacco Control, Mongolia, 31 March 2007; Tobacco is your enemy [newsletter in Mongolia] December 2006; p. 3; Global Youth Tobacco Survey 2000, Trinidad and Tobago fact sheet. Available at: http://www.cdc.gov/tobacco/global/GYTS/factsheets/paho/factsheets.htm; Mexico: Global Youth Tobacco Survey 2003, Mexico fact sheet. Available at: http://www.cdc.gov/tobacco/global/GYTS/factsheets/paho/factsheets.htm

40. Personal communication from T. Szilágyi, Health 21 Hungarian Foundation, 15 March 2007, based on information from Hungarian media coverage.

41. Personal communication from L. Ligabalavu, Ministry of Health, Fiji, 25 March 2007.42. Personal communication from B. Rosted, Norwegian Cancer Society, 12 March 2007.43. Personal communication from K. Lindorff, VicHealth Centre for Tobacco Control, Australia, 26 March 2007, based on

information from Australian state/territory reports.44. Personal communication from M. DeRosenroll, Canadian Cancer Society, 23 March 2007, based on information from

Canadian Cancer Society and Physicians for a Smoke-free Canada.45. Personal communication from S. Bradbrook, Te Reo Marama – Maori Smokefree Coalition, 26 Marc 2007. Based on

information from discussions with Public Health Unit (New Zealand).46. Pictures of minors buying and selling tobacco products retrieved 16 March 2007 from: http://gallery.globalink.org/

v/members/goswamih ; S. Johal. Educational institutions not following norm, The Hindustan Times (Chandigarh ed.) 31 May 2005; S. Mehta. Cigarette, tobacco act fails to get implemented, The Hindustan Times (Chandigarh ed.) 1 May 2005; K. Abhimanyu. How will they take action (Translated from Hindi), Dainik Bhaskar 24 March 2007.

47. Personal communication from T. Szilágyi, Health 21 Hungarian Foundation, 15 March 2007.48. Personal communication from L. Ligabalavu, Ministry of Health, Fiji, 25 March 2007.49. Personal communication from K. Lindorff, VicHealth Centre for Tobacco Control, Australia, 26 March 2007, based on

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information from Australian state/territory reports.50. Personal communication from M. DeRosenroll, Canadian Cancer Society, 23 March 2007, based on information from

Canadian Cancer Society; Physicians for a Smoke-free Canada.51. Personal communication from C. Otto and A. Lyman, Coalition for a Tobacco-Free Palau, 15 March 2007. Based on

information from Annual Synar Reports submitted annually to the US Substance Abuse and Mental Health Services Administration (SAMHSA) and Center for Substance Abuse Prevention (CSAP).

52. M.D. Mohee, head, prevention and education unit, Ministry of Health, Mauritius; personal communication from V. LeClezio, ViSa Mauritius, 3 April 2007. based on information from interview with M.D. Mohee.

53. H. Goswami, 24 March 2007, Burning Brain Society. He bases his info on the same photo-documentation pictures of minors buying and selling tobacco products available at: http://gallery.globalink.org/v/members/goswamih ; S. Johal. Educational institutions not following norm, The Hindustan Times (Chandigarh ed.) 31 May 2005; S. Mehta. Cigarette, tobacco act fails to get implemented, The Hindustan Times (Chandigarh ed.) 1 May 2005; K. Abhimanyu. How will they take action [translated from Hindi], Dainik Bhaskar 24 March 2007.

54. Kengganpanich, M., et al. The local administration of tobacco control. Bangkok: Tobacco Control Research and Knowledge Management Center, 2007.

55. Personal communication from E. Bianco, Research Centre of the Tobacco Epidemic, Uruguay, 27 March 2007.56. Executive Decree 17, Article 22, 11 March 2005, Panama. 57. Pictures of minors buying and selling tobacco products available at: http://gallery.globalink.org/v/members/

goswamih; S. Johal. Educational institutions not following norm. The Hindustan Times (Chandigarh ed.) 31 May 2005; S. Mehta. Cigarette, tobacco act fails to get implemented, The Hindustan Times (Chandigarh ed.) 1 May 2005; K. Abhimanyu. How will they take action [translated from Hindi], Dainik Bhaskar 24 March 2007.

58. Personal communication from M. DeRosenroll, Canadian Cancer Society, 23 March 23 2007, based on information from Canadian Cancer Society; Non-Smokers’ Rights Association.

59. Personal communication from F.J. López Antuñano, Alianza Contra el Tabaco, A.C., Mexico, 31 March 2007.60. Tilson, M. A critical analysis of youth access laws. Ottawa: Canadian Cancer Society, 2002.61. Central Intelligence Agency. The World Factbook, 2007. Retrieved 3 May 2007 from: https://www.cia.gov/library/

publications/the-world-factbook/index.html 62. Ling, P.M., Landman, A., & Glantz, S.A. It is time to abandon youth access tobacco programmes. Tobacco Control 2002; 11: 3–6.63. Fong, G.T., Cummings, K.M., Borland, R., Hastings, G., Hyland, A., Giovino, G.A., Hammond, D., & Thompson, M.E. The

conceptual framework of the international tobacco control (ITC) policy evaluation project. Tobacco Control 2006; 15(Suppl. 3): 3-11.

64. Last, J.M. A dictionary of epidemiology. 4th ed. New York: Oxford University Press, 2001.65. Giovino, G.A., Schooley, M.W., Zhu, B.P., Chrismon, J.H., Tomar, S.L., Peddicord, J.P., Merritt, R.K., Husten, C.G., &

Eriksen, M.P. Surveillance for selected tobacco-use behaviours – United States, 1900-1994. Morbity & Mortality Weekly Report: Centers for Disease Control and Prevention Surveillance Summary 1994; 18: 1-43.

66. Departamento de investigación sobre tabaco. Instituto Nacional de Salud Pública. Retrieved 14 May 2007 from: http://www.insp.mx/tabaco/

67. Personal communication from N. Movsisyan, American University of Armenia, 3 April 2007.68. Personal communication from K. Lindorff, VicHealth Centre for Tobacco Control, Australia, 26 March 2007.69. Personal communication from H. Goswami, Burning Brain Society, 24 March 2007.70. Personal communication from K. Chultem, ADRA Mongolia, and T. Baljinnyam, Children, Youth, and Family Association,

31 March 2007.71. Personal communication from C. Otto and A. Lyman, Coalition for a Tobacco-Free Palau, 11 June 2007.72. Le chiffre 17. L’express 11 July 2004. Retrieved 14 May 2007 from: http://www.lexpress.mu/display_search_result.

php?news_id=2183273. Warren, C.W., Riley, L., Asma, S., Eriksen, M.P., Green, L., Blanton, C., Loo, C., Batchelor, S., & Yach, D. Tobacco use

by youth: A surveillance report from the global youth tobacco survey project. Bulletin of the World Health Organization 2000; 78: 868-762.

74. Warren, C.W., Jones, N.R., Eriksen, M.P., & Asma, S. for the Global Tobacco Surveillance System (GTSS) collaborative group. Patterns of global tobacco use in young people and implications for future chronic disease burden in adults. 17 February 2006. Available at: http://www.cdc.gov/cogh/publications/05art8184page.pdf

75. Nebot, M., Lopez, M.J., Gorini, G., et al. Environmental tobacco smoke exposure in public places of European cities. Tobacco Control 2005; 14: 60-3.

76. Giovino, G.A., Schooley, M.W., Zhu, B.P., Chrismon, J.H., Tomar, S.L., Peddicord, J.P., Merritt, R.K., Husten, C.G., & Eriksen, M.P. Surveillance for selected tobacco-use behaviours – United States, 1900-1994. Morbity & Mortality Weekly Report: Centers for Disease Control and Prevention – Surveillance Summary 1994; 18: 1-43.

77. Navas-Acien, A., Peruga, A., Breysse, P., et al. Second-hand tobacco smoke in public places in Latin America, 2002-2003. Journal of the American Medical Association 2004; 291: 2741-2745.

78. Norwegian Institute for Alcohol and Drug Research. Retrieved 14 May 2007 from http://www.sirus.no79. Tobacco Control Act no. 6/2002. Iceland.80. All comments in this box are from data collectors for each country mentioned.

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In implementing tobacco control measures that reduce tobacco consumption, it is vital that parties develop robust strategies and strong programming infrastructures. These include a resourced and planned approach that ensures all tobacco control measures are based on solid evidence by designated authorities and that collaborations take place within a stipulated time frame and have evaluative ends. This chapter explores the strategies, processes, and stakeholders that parties have identified in meeting their FCTC obligations. Because the role of civil society organizations such as the Framework Convention Alliance (FCA) has been widely recognized in the development of the treaty, the chapter also describes the varied roles of nongovernmental organizations in the implementation of FCTC provisions in party countries, in the post-ratification phase.

Provisions of the FCTC that Address Broader Tobacco Control Issues

Under article 5.1, each party to the FCTC is obliged to create and maintain comprehensive multisectoral national tobacco control strategies, plans, and programs in accordance with the convention and any protocols to which it is a party. Towards this end, article 5.2 requires each party, “in accordance with its capabilities,” to: “establish or reinforce and finance a national coordinating mechanism or focal points for tobacco control” (article 5.2a); and “adopt and implement effective legislative, executive, administrative and/or other measures and cooperate, as appropriate, with other Parties in developing appropriate policies for preventing and reducing tobacco consumption, nicotine addiction and exposure to tobacco smoke” (article 5.2b). To achieve the objective of the FCTC, state parties to the convention agree under article 4.7 to be guided by the principle that “the participation of civil society is essential in achieving the objective of the Convention and its protocols.” Parties also emphasize, in the preamble to the convention, “the special contribution of nongovernmental organizations and other members of civil society not affiliated with the tobacco industry, including health professional bodies, women’s, youth, environmental and consumer groups, and academic and health care institutions,

to tobacco control efforts nationally and internationally and the vital importance of their participation in national and international tobacco control efforts” (preamble).

Parties to the FCTC also recognize “the need to be alert to any efforts by the tobacco industry to undermine or subvert tobacco control efforts and the need to be informed of activities of the tobacco industry that have a negative impact on tobacco control efforts” (preamble), and agree that in setting and implementing their public health policies with respect to tobacco control they shall “act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law” (article 5.3).

Findings from the 2007 FCA FCTC Monitor

Tobacco Control Program Infrastructure National office/ focal point for tobacco control

Of the 27 countries participating in the 2007 FCA FCTC Monitor, 23 countries have either a national office or a focal point for tobacco control, mostly based in a ministry of health. As the shaded box indicates below, the responses range from having a full-fledged division or agency on tobacco control as in Thailand, Fiji, and Canada;1 to a person dedicated to tobacco control as in Japan; a WHO focal point coordinating the national tobacco control program in Armenia; to an officer in the ministry of health being assigned additional responsibility as the focal point for tobacco control such as in the South Asian countries of Bangladesh, India, and Sri Lanka.2

National plan for tobacco control

As table 9.1 indicates, data collectors from 19 of the 27 participating countries report having a national action plan for tobacco

CHAPTER 9 BROADER TOBACCO CONTROL ISSUES Shoba John

Variations in national focal points for tobacco control

Fiji: A national office known as the Tobacco Control Unit (exists) under Ministry of Health.

India: There is no full-time focal point, independent department or office for tobacco control. An officer in the Union Ministry of Health at the joint secretary level is given charge of tobacco control.

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control. Six participating countries, including Ghana, Kenya, India, Mauritius, Trinidad and Tobago, and Uruguay do not have a national tobacco control plan yet. Out of these, Ghana, Mauritius, and Uruguay have draft plans that are awaiting government approvals and Trinidad and Tobago expects to develop one.3 On the other hand, Hungary has a national plan that is currently not funded, and Jordan’s plan has expired (in 2006) and needs updating.4 In the case of Japan and Sri Lanka, data collectors are unable to determine if the countries have a specific plan for tobacco control.

Overall, the high-income participating countries like Australia, Canada, Iceland, Norway, and New Zealand have developed long-term strategies for tobacco control.5 The participating low-, lower-middle-, and upper-middle-income countries with long-term plans include Bangladesh, Pakistan, Panama, Peru, and Slovakia.6 Pakistan has its tobacco control plans integrated with its strategy for non-communicable diseases and other countries have integrated it with their drug-prevention policies.7 Australia has a National Tobacco Strategy for 2004-09, with unique inclusiveness in its objectives and process. The strategy reflects the joint commitments of its federal, state, and territorial governments “to work together and in collaboration with non-government agencies on a long-term, comprehensive, evidence-based and coordinated national plan to reduce the harms caused by tobacco.”8

Interministerial committee for tobacco control

An interministerial committee is generally set up between the ministers of various stakeholder ministries aiming to develop a coordinated approach to tobacco control and often lends leadership to policy and program initiatives within a country. Over half the participating countries have interministerial committees. While some of these countries such as Ghana, Peru, Slovakia, Sri Lanka, and Thailand have

official committees represented by various ministries set up solely to address tobacco control issues, others like Bangladesh have held occasional intersectoral meetings or sought input from other ministries on tobacco control issues.9 In countries like New Zealand and Australia, the ministerial council on drugs addresses tobacco control concerns as well.10 Mauritius and Norway have nongovernmental organizations in their committees.11

Of the countries that do not have an

interministerial committee, Canada has an intergovernmental committee of officials from federal, provincial, and territorial governments.12 Trinidad and Tobago and Uruguay have plans to establish interministerial committees concerned with tobacco control.13

Funding for national tobacco control

Figure 9.1 describes the funding for tobacco control in the 22 countries where data collectors reported funding sources (in some countries, there was more than one source reported). Eleven countries have governmental funds specifically designated for tobacco control. In another five, tobacco control activities are supported within budgets for other purposes, but with no earmarked funding for tobacco control. The World Health Organization is mentioned as a funder in five countries; other sources include CIDA, CDC, the World Bank, and PAHO. Thailand and Iceland are the only countries with a dedicated tax on tobacco products that supports tobacco control programs.14 The shaded box on page 76 describes Thailand’s approach to tobacco control programming and its infrastructure.


Yes, have a national plan (n=19)

Madagascar CanadaMexicoPanamaPeru

JordanPakistan

ArmeniaIcelandHungaryNorwaySlovakia

BangladeshThailand

AustraliaFijiMongoliaNew ZealandPalau

No, do not have national plan (n=6)

GhanaKenyaMauritius

Trinidad & TobagoUruguay

India

Unable to determine(n=2)

Sri Lanka Japan

Table 9.1. Countries with/without a national plan for tobacco control, by WHO region

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Countries such as Pakistan, Peru, and Trinidad and Tobago have no budgetary allocations for tobacco control.15 Thus, in most of the participating countries, there is no earmarked budget or consistent source of funding for tobacco control. Even in high-income countries like Canada, the federal government nearly halved the funding that was planned for its federal tobacco control strategy in 2006-07. Countries found it difficult to determine the actual estimates of funding for tobacco control.

Civil Society Participation in National Tobacco Control

Overall, there is higher NGO involvement in policy development (in 13 of the 27 participating countries) than in program implementation (9 countries) or in monitoring policies or programs (8 countries). While the reasons for this trend cannot be ascertained with the data available, they could vary from there being fewer opportunities for program implementation and monitoring to fewer NGOs being invited or able to contribute in these areas. In Fiji, for example, there is no NGO specifically targeting tobacco control, and NGOs there have other priorities.16

Data collectors from high-income countries like Australia and Canada report significant NGO involvement in federal policy-making while provincial and territorial NGOs are active in program implementation such as running quitlines or educational and counter-advertising campaigns. Challenges to civil society participation in

national tobacco control

Data collectors from countries with low incomes or unstable sources of funding for national

Sustainable tobacco control program infrastructure

Thailand, a middle-income country in South East Asia, reported a robust infrastructure for tobacco control programming. It has a multipronged tobacco control program in the Ministry of Health, with its different divisions addressing policy development, enforcement, public awareness, media campaigns, and cessation support. The tobacco and alcohol control group in the bureau of non-communicable diseases, Ministry of Public Health serves as the national office and focal point for tobacco control in the country. Thailand also has a national plan for tobacco control and a national committee for control of tobacco use that steers its tobacco control program.

The country received 10 million bahts (approximately 303,700 USD) from general taxes to the tobacco and alcohol control group in Ministry of Public Health that oversees tobacco control in the country. Additionally, the Thai Health Promotion foundation, resourced by tobacco and alcohol taxes, funds tobacco control projects. This systematic and well-resourced approach to tobacco control helps them in meeting their FCTC obligations, revising their national action plans, evaluating the efficacy of measures in reducing tobacco use, and in strengthening national policies.

State funds allocated to tobacco control

State funds specifically for tobacco control

Other sources (CIDA, CDC, World Bank, PAHO)

Unknown

0 2 4 6 8 10 12

Number of countries

WHO

*Other sources include Canadian International Development Agency, Centers for Disease Control and Prevention, World Bank, and Pan American Health Organization.

Figure 9.1. Funding sources for tobacco control

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tobacco control programs cite the lack of resources as a limiting factor in implementation. This may partly explain the greater involvement of civil society in these countries in policy-development efforts that are less resource intensive. Data collectors from a few countries, including India, Sri Lanka, and Slovakia suggest the need for improved trust between government and NGOs for greater contribution to development, implementation, and monitoring of national tobacco control programs and policies. Data collectors also listed other constraints to meaningful civil society participation, such as: lack of NGO capacity and reach; absence of formal channels of interaction with the government; absence of dedicated staff in the government for liaisons with NGOs; a restrained civil rights environment; and a perceived fear of certain NGOs as representing the industry.

National tobacco control coalitions

Twenty of the 27 participating countries have national tobacco control coalitions. In Bangladesh, the national networks collaborate and contribute consistently to government tobacco control efforts (see box).17 Some countries have multiple networks. Some have networks with national reach, while others are limited to certain cities, health professional groups, or certain interventional strategies. Fiji, Jordan, Mauritius, Mongolia, and Slovakia do not have any tobacco control coalitions.

Collaborations with international tobacco control organizations

NGOs in 23 of the participating countries have collaborations with international tobacco control organizations. An equal number reported liaisons with the Framework Convention Alliance.

Government funding for NGO tobacco control programs

Government funding for tobacco control programs is nearly non-existent or limited in most of the low- and middle-income countries with the exception of Armenia, Pakistan, and Thailand. NGOs in high-income countries report some degree of government funding.

Media coverage of tobacco control

Media coverage of tobacco control in seven countries is high. The majority of participating countries have a “moderate” level of media coverage about tobacco control. This suggests that media carry tobacco control news occasionally, or with a selectivity regarding issues, or under certain circumstances. Sixteen countries have moderate media coverage of tobacco control while another three have relatively low coverage, with information missing from one country.

In terms of themes for coverage, the media tend to be supportive in covering 100 percent smoke-free policies (in 21 of the 27 participating countries) and also supportive in covering the FCTC (in 17 countries). There is more neutral or mixed reporting than there are supportive postures on marketing bans (15 countries vs. 9 countries) and taxation (16 countries vs. 7 countries) – issues that are perceived to have direct impact on their own business and the larger economy. Regarding funding for tobacco control, the media give supportive or neutral messages in an equal number of countries. Only a small number of participating countries appear to experience “contrary” reporting on any of these aspects of tobacco control.

Industry Interference and Agreements

A majority of the data collectors report that their countries have not signed any public agreement with the tobacco industry. Mexico has signed three agreements with the tobacco industry, the

Vibrant government-NGO collaboration in tobacco control

Bangladesh represents the scope for civil society participation and collaboration with the government on tobacco control. The country has an extended network of over 500 NGOs spread throughout the country in the Bangladesh Anti-Tobacco Alliance. They have advocated for policy changes, contributed to the drafting of the tobacco control law and rules, and are currently involved in programme implementation with the Ministry of Health and WHO. The extensive reach of the network helps in effective law monitoring throughout the country. They have also established international linkages with the Canadian International Development Agency, Framework Convention Alliance, and HealthBridge, and with whom they exchange technical and financial expertise and resources.

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first one allowing the industry’s self-regulation, the second along the lines of international marketing standards, and the third one accepting industry sponsorship of the National Fund against Catastrophic Expenses for Health.18

While formal government agreements with the industry are fewer, in Bangladesh the industry has sponsored small events and the Iceland data collector describes tobacco industry sponsorship offers to the government. The Hungarian Customs and Finance Guard has a collaborative agreement with the Hungarian Association of Tobacco Manufacturers on combating smuggling.19

Reporting system for tobacco industry political contribution

Twenty of the participating countries have no system for reporting political contributions by the tobacco industry. Australia and Canada have legislation that addresses disclosure of political contributions and lobbying, though not specifically by the tobacco industry.20

Political interference by the tobacco industry

Overall, data collectors from 14 countries report industry efforts to influence laws, regulations, and/or government enforcement. In Australia, the industry succeeded in lobbying the federal government to water down their proposed measures to have graphic health warnings on 50 percent of the front and back of cigarette

packs, to having 30 percent of the front and 90 percent of the back of packs covered – the industry’s preferred option. In Bangladesh, the industry was reportedly present during drafting of the law and rules and lobbied hard to prevent laws from being strong; they also got hold of drafts and watered them down between meetings. It required constant vigilance to strengthen them again but some compromises were inevitable due the inability of government officials to withstand their constant pressure.21 In Mexico, there has been direct lobbying of key stakeholders in the Government.22

The tobacco industry (local producers and importers) holds seats in the Armenian National assembly.23 In India, the Indian Tobacco Company (ITC) donated 44 million rupees (1,093,000 USD) to major political parties and listed the donation in its balance sheet to claim tax benefits. ITC Limited and Godfrey Phillips are known to involve many political leaders and dignitaries in their corporate social responsibility activities such as blood donation drives, bravery awards and e-Choupal activities among farmers.24 Other data collectors report industry infiltration into key ministries of government and other statutory bodies as in Fiji, infiltration into tobacco control committees of the government in Mauritius, and dilution or delay in policies as in Kenya, offering company shares in Jordan, or positions on industry boards as in Pakistan and using front groups to do so.25

Youth smoking-prevention programs

Youth smoking-prevention programs are designed by the tobacco industry to covertly increase youth initiation to smoking, improve the industry’s image, and subvert policy efforts. Nine participating countries have the tobacco industry supporting smoking-prevention

Varying media coverage in countries

Armenia: Between 2003-2005, the media coverage increased from none to dozens of articles in print media. This increase was a result of the journalists’ training and media partnerships built through an OSI-funded project of the Armenian Public Health Alliance. Furthermore, the level of coverage of tobacco control issues increased in 2006 because of greater involvement of NGOs in tobacco control.

Mauritius: Some newspapers report press conferences on tobacco control but others downplay the issue because they publish indirect tobacco advertising for British American Tobacco. Some journalists are also taken to forum parties of the tobacco industry abroad.

Palau: The coalition has an excellent relationship with the news media. At one time, the media was represented on the coalition. They will cover events (e.g., World No Tobacco Day walk-a-thon) and print almost any article we submit free of charge.

Political donations reporting - The Australian way

Australia: National legislation governs the disclosure of donations to political parties. The parties must state in an annual return the name and addresses of those whose donations for the year have exceeded a specified threshold. Some political parties, including the Australian Labor Party, the Australian Greens, and the Australian Democrats, but not the Liberal Party or the National Party, have stated that they will not accept donations from tobacco companies.

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programs though in six countries the industry’s involvement in the program could not be determined. The remaining 11 countries did not identify any industry-run smoking-prevention programs.While few countries have direct public agreements with the tobacco industry, the industry’s political contributions and support for youth smoking-prevention programs reflect the extent of industry influence on tobacco-control decision making and policies. In nine participating countries, the industry runs youth smoking-prevention programs, which indicates the industry’s indirect presence and influence

within the parties. With only three countries having restrictive measures such as reporting on the industry’s political contributions, tobacco control in most countries appears highly vulnerable to industry influence and lobbying.

Recommendations

1. Resourcing tobacco control. Financial resources are a major challenge for tobacco control infrastructure programming in most

countries. The experience of high-income countries like Canada reveals that general government budgets do not provide a stable source of funding for tobacco control. On the other hand, countries like Thailand with taxes specifically earmarked for tobacco control report self-sufficiency in funding strategic tobacco-control measures and FCTC implementation. Raising tobacco taxes and earmarking them for health promotion and tobacco control affords a stable and sustainable source of funding for tobacco control. This in turn could substantially improve the government infrastructure for tobacco control programming and support civil society’s contribution to program and policy efforts.

2. Improving media coverage of tobacco control. Countries that report supportive media coverage obtain it mostly as “earned” media, which highlights the need to focus on low-cost media advocacy efforts. The success stories clearly indicate that targeted and sustained nurture, engagement, and exposure of the media to specific tobacco control issues greatly enhance its coverage. Linking tobacco control with larger developmental and human rights issues seems to help the media to broaden the debate and find interesting news angles. In keeping with article 4.1 of the FCTC, parties need to undertake specific measures to improve media coverage of tobacco control issues and resource them adequately.

3. Protection from industry interference. In the absence of specific safeguards against tobacco industry interference in the majority of the participating countries, parties need to develop and utilize appropriate measures to protect their tobacco control policies and programs. Therefore, article 5.3’s guidelines that describe specific measures to protect government policies and programs on tobacco control from industry interests are both timely and critical.

Tobacco industry inroads to Mexico

The tobacco industry in Mexico has indulged in extensive lobbying of politicians to derail the tobacco control efforts in the country. This includes:• Congress members being lobbied to impede general

health law reforms and stronger measures for tobacco control (such as increases in tobacco taxes at least twice since Mexico ratified the FCTC);

• Ministry of Agriculture being alerted to (unfounded) fears about loss of employment for tobacco producers;

• Ministry of Economy being influenced about tobacco and free trade under NAFTA, loss of industrial jobs, and international investment from tobacco control;

• Ministry of Finance being lobbied about increasing smuggling, losing tax income by increasing tobacco taxes.

• Ministry of Health being persuaded to sign public agreements on self-regulation of the tobacco industry and industry sponsorship of the health fund; and

• Smoke-free policies are diluted through the “Courtesy of Choice” program in restaurants, bars, nightclubs, and hotels.

Notes1. Executive summary: Measures for tobacco and alcohol control. National plan for tobacco and alcohol. Department

of Disease Control, Ministry of Public Health, Thailand, 2005; Personal communication from L. Ligabalavu, Ministry of Health, Fiji, 25 March 2007; unpublished Canadian government report to the second session of the Conference of Parties, section 1, March 2007.

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2. Personal communication from: M. Sakuta, Japanese Society for Tobacco Control, 15 March 2007, based on information from Ministry of Health, Japan; N. Movsisyan, American University of Armenia, 3 April 2007; S.M. Alam Tahin, WBB Trust (Work for a Better Bangladesh), and S. Ahmed, Bangladesh Anti-Tobacco Alliance (BATA); H. Goswami, Burning Brain Society, and M. Arora Health-Related Information Dissemination Amongst Youth (HRIDAY), India, 24 March 2007; O. Gunasekera, ADIC Sri Lanka, and M. Peiris, Jeewaka Foundation, 26 March 2007.

3. Wellington, E. Tobacco-control efforts in Ghana Presentation to Health Canada, February 2007; personal communication from M.D. Mohee, head of the education and prevention unit of the Ministry of Health, Mauritius, 3 April 2007; Ministry of Health, Tobacco Control Advisory Committee, Uruguay; Ministry of Health, Trinidad and Tobago.

4. Personal communication from T. Demjén, head of department, National Institute for Health Development, Hungary, 15 March 2007; National focal point of tobacco control, Ministry of Health, Jordan, 4 April 2007.

5. Ministerial Council on Drug Strategy. National tobacco strategy 2004-2009: The strategy. Australian Government Department of Health and Ageing. November 2004. Retrieved 10 May 2007 from: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strateg-drugs-tobacco-policy.htm ; personal communication from: M. DeRosenroll, Canadian Cancer Society, 23 March 2007; V. Jensson, Public Health Institute of Iceland, 4 April 2007; The Directorate for Health and Social Affairs. Tobacco campaigns. Norway. Available at: http://www.shdir.no ; Clearing the smoke: A five-year plan for tobacco control in New Zealand 2004–2009. September 2004. Available at: http://www.moh.govt.nz

6. National Policy and Plan of Action for Tobacco Control in Bangladesh, 2007-2010. Ministry of Health and Family Welfare; National action plan for the prevention and control of non communicable diseases in Pakistan. Ministry of Health, WHO and HeartFile, 2004. Available at: http://www.heartfile.org/pdf/PDAppendix%20B.pdf ; National plan for tobacco prevention and control, 2000-2005, Panama; National program for the fight against drugs for 2004-2008, Peru; General secretariat board of ministers for drug dependencies and drug control, Slovakia. Available at: http://www.infodrogy.sk

7. Personal observation of Pakistan data collector, E. Latif, Society for Alternative Media and Research, 13 March 2007.8. National Tobacco Strategy 2004-2009: The Strategy. Ministerial Council on Drug Strategy. Australia. Department

of Health and Ageing. November 2004. Retrieved 10 May 2007 from: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-pubhlth-strateg-drugs-tobacco-policy.htm

9. Personal communication from S.M. Alam Tahin, WBB Trust (Work for a Better Bangladesh), and S. Ahmed, Bangladesh Anti-Tobacco Alliance (BATA), 16 March 2007.

10. National drug policy, New Zealand. Ministerial committee on drug policy. Retrieved 10 May 2007 from: http://www.ndp.govt.nz/committees/mcdp.html ; Ministerial council on drug strategy. Australia. Retrieved 10 May 2007 from: http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/mcds-lp

11. Directorate for health and social affairs in Norway. Retrieved 10 May 2007 from: http://www.shdir.no ; personal communication from: V. LeClezio, ViSa Mauritius, 3 April 2007. Bjarne Rosted, Norwegian Cancer Society, 12 March 2007.

12. Personal communication from M. DeRosenroll, Canadian Cancer Society, 23 March 2007. 13. Personal communication from C. Alexis-Thomas, Coalition for Tobacco-Free Trinidad and Tobago, 26 March 2007.14. Discussion of the Tobacco Research Centre Working Group, Thailand, 13 March 2007; http://www.thaihealth.or.th/

english/?PHPSESSID=hslfhf6tisbb6dlt627vemu5l6 ; Tobacco Control Act no. 6/2002. Iceland.15. Ministry of Finance, Annual budget statement, Pakistan, 2006; C.F. Alburqueque, Comisión Nacional Permanente de

Lucha Antitabaquica (COLAT), Peru, 4 April 2007, based on information from Ministry of Health; C. Alexis-Thomas, Coalition for Tobacco-Free Trinidad and Tobago, meeting with Ministry of Health, Trinidad & Tobago, 26 March 2007.

16. Personal communication, L. Ligabalavu, Ministry of Health, Fiji, 25 March 2007.17. Personal observation of Bangladesh data collector. S.M. Alam Tahin, WBB Trust (Work for a Better Bangladesh), and S.

Ahmed, Bangladesh Anti-Tobacco Alliance (BATA) – 16 March 2007.18. F.J. López Antuñano, Alianza Contra el Tabaco, A.C., Mexico, 31 March 2007.19. Personal observation of Bangladesh data collector. S.M. Alam Tahin, WBB Trust (Work for a Better Bangladesh), and

S. Ahmed, Bangladesh Anti-Tobacco Alliance (BATA) – 16 March 2007; personal communication from V. Jensson, Public Health Institute of Iceland, 4 April 2007; personal communication from T. Szilágyi, Health 21 Hungarian Foundation, 15 March 2007.

20. Australian Electoral Commission. Available at: http://www.aec.gov.au ; Victorian Electoral Commission. Available at: http://www.vec.vic.gov.au; Canada Elections Act, 2000. Available at: http://laws.justice.gc.ca/en/E-2.01 ; Lobbyists Registration Act, 1985. Available at: http://laws.justice.gc.ca/en/L-12.4 ; personal communication from M. DeRosenroll, Canadian Cancer Society, 23 March 2007, based on information from Canadian Cancer Society; personal communication from B. Rosted, Norwegian Cancer Society, 12 March 2007.

21. Personal communication from: K. Lindorff, VicHealth Centre for Tobacco Control, Australia, 26 March 2007; S.M. Alam Tahin, WBB Trust (Work for a Better Bangladesh), and S. Ahmed, Bangladesh Anti-Tobacco Alliance (BATA), 16 March 2007.

22. F.J. López Antuñano, Alianza, Contra el Tabaco, A.C., Mexico, 31 March 2007.23. List of MPs, National Assembly of the Republic of Armenia. Retrieved 15 March 2007 from: http://www.parliament.am24. ITC limited homepage, available at: http://www.itcportal.com ; Godfrey Phillips homepage available at: http://www.

godfreyphillips.com ; and http://www.burningbrain.org25. L. Ligabalavu, Ministry of Health, Fiji, 25 March 2007; Le tabac illégal ne fera pas long feu, L’Express, 30 September

2006. Available at: http://www.lexpress.mu/display_search_result.php?news_id=73319 ; personal communication from A. Ogwell, Oral and Craniofacial Research Associates, Kenya, 4 April 2007; Ministry of Health, Jordan; Pakistan Tobacco Company. Available at: http://www.ptc.com.pk

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This chapter provides a worldwide overview of the WHO Framework Convention on Tobacco Control (FCTC) and provides recommendations to the Conference of the Parties (COP) for accelerating its implementation process. Unlike the previous chapters of the report that focus on the implementation of the FCTC provisions in individual countries, this chapter draws from broad expertise to provide a global commentary.

The Global Tobacco Death Clock, unveiled on the first day of each of the International Negotiation Body (INB) meetings of the FCTC, was a constant reminder to the delegates of what delays in action mean in terms of human life. With an estimated death toll of over 5 million in one year, tobacco has already caused over 10 million deaths since the FCTC entered into force on 27 February 2005. According to the World Health Organization, with the elapse of every 6.5 seconds there is one more death in some part of the world due to tobacco use.1 This sobering fact explains the urgency for implementation of the treaty provisions. If the oft-quoted aim of protecting the present and future generations from the devastating health, social, environmental, and economic consequences of the global tobacco epidemic (article 3) is to be fulfilled, it is incumbent on the parties to install all systems required for effective implementation of the FCTC as early as possible.

Initial Momentum

The response of state governments to early ratification of the FCTC was so high that within twenty months of its approval by the World Health Assembly (WHA), the 40th instrument of ratification was deposited to enable the FCTC to come into force on 27 February 2005. It was the first global public health treaty negotiated under the auspices of the World Health Organization, and it is one of the most widely and rapidly supported treaties in the history of the United Nations. Even the WHO did not foresee the unprecedented response — funds to hold the first session of the COP, which the WHO was obliged to hold within one year of the entry into force (article 23.1), were found only after much pressure by certain governments and by civil society. As of May 2007, one month before

COP-2, the number of countries that has ratified the FCTC stands at 147, representing over 75 percent of the world’s population.

Positive Developments Since the First COP

Since the FCTC entered into force, several positive developments have unfolded. Around the world today, there is a greater awareness of the hazards of tobacco use and a more affirmative attitude towards implementation of tobacco control policies. The grant by Michael Bloomberg, mayor of New York City, of 125 million US dollars for tobacco control work is a case in point. This is the first time in history that such a large amount of money has been made available for tobacco control work and it has helped in activating many programs. The FCTC has also provided the impetus for many countries to enact, examine, and/or amend tobacco control legislation (as the preceding chapters report), and to provide the necessary legal environment for more effective implementation. More particularly, there has been a significant response to article 8, which deals with protection from exposure to tobacco smoke, and guidelines have been formulated for consideration by the COP-2. There has also been progress on article 11, that is, packaging and labelling of tobacco products, which the parties are obliged to adapt and implement within a period of three years after entry into force of the FCTC for that party, and article 13 – tobacco advertising, promotion, and sponsorship, which is the subject for the development of a protocol and guidelines. Another very positive development involves the opportunities for civil society’s participation in the FCTC process. Beginning with the increase in opportunities for interventions at the COP-1 that allowed civil society to make timely and meaningful contributions that informed the deliberations, there was active participation of civil society in the two working groups convened for the elaboration of guidelines on article 8 and on articles 9 and 10; the two expert groups to prepare templates for protocols on illicit trade and cross-border advertising, promotion, and sponsorship on the basis of articles 15 and 13.8 of the FCTC respectively; and the alternative crops meeting that followed the COP-1. Overall, this approach gave life to the provisions

CHAPTER 10 THE WHO FRAMEWORK CONVENTION ON TOBACCO CONTROL (FCTC) PROCESS Olcott Gunasekera

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in the convention about the importance of the role of civil society. For this change the role played by several key players has to be acknowledged, namely: the COP as a whole; the Bureau of the Conference of the Parties, which made the decision that enabled the protocol expert groups to invite civil society experts; the interim secretariat, which has been very accommodating to nongovernmental organizations; the chairs of the expert groups; and the key facilitating countries. Civil society participation as equal partners should become the normal practice not only at the international level but also at the national levels when implementing the FCTC, as is emphasized in article 4.7 and paragraph 17 of the preamble to the convention.

Areas of Concern

One of the main reasons for giving a 16-month gap between the COP-1 and the COP-2 was to make certain that the permanent secretariat of the COP was fully operational before the COP-2. However, the permanent COP secretariat has still not yet been established. The Tobacco Free Initiative (TFI) of the WHO, which acted as the interim secretariat, has to be commended for all the hard work done to implement the decisions of the COP-1. But the implementation of the FCTC is only one of the functions of the TFI. It has a wider portfolio of work because it has to respond to the needs of all the member states of the WHO, not just those who are parties of the FCTC. A COP secretariat, on the other hand, will have on its agenda only the implementation of the provisions of the FCTC and any other related matters. Whatever the reasons are for the permanent COP secretariat’s non-functioning, it is an urgent matter of concern.

Another matter of concern is the delay by parties in the payment of their voluntary assessed contributions, which is necessary to fund the essential work of the COP and the secretariat.2 A steady flow of financial resources, outside special funding, is essential for the smooth functioning of the COP secretariat and to fulfill the international obligations of the FCTC. In the new Health, Nutrition, and Population (HNP) strategy of the World Bank,3 there is no forthright endorsement of the urgency of

implementing the provisions of the FCTC as a strategy to lower the disease burden. This is in spite of the fact that tobacco use and addiction is recognized as a major cause for premature deaths related to noncommunicable diseases (such as diabetes, pulmonary diseases, hypertension, and cancer) and is predicted to become the leading cause of death in low-income countries by 2015.4

It is, therefore, a matter of serious concern that the initial momentum behind the FCTC may be waning gradually, superseded by other priorities. This has to be viewed in the context of the attempts by the tobacco industry to undermine the FCTC process, besides following a rigorous policy to expand its markets. The question that may be raised is whether the efforts put into the FCTC process by all the stakeholders are matching that of the industry.5 Hence at the COP-2, parties will have to find strategies to ensure that there is a sustained and well-focused effort to implement the FCTC provisions in order to create a perceptible dent in the present expansion of the tobacco market.

Suggested Actions

1. The COP-2 should determine a definite timeline for the establishment of the permanent secretariat and expedite the process. For more focused implementation of the provisions of the FCTC, the early establishment of the permanent secretariat is a must.

2. The financial base for the implementation of the FCTC should be strengthened and measures should be adopted at the COP-2 to ensure that the financial obligations of each party are fulfilled expeditiously.

3. The FCTC, both in the preamble and in

specific articles, recognizes the important role that the nongovernmental sector could play in its implementation. This was well demonstrated at the COP-1 and in the post COP-1 period. Learning from this experience, civil society should participate as equal partners with the state sector and this should be made the norm, both at the national and international levels for which the necessary procedural rules should be adopted. Parties should be encouraged to create at the

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national level a suitable mechanism to ensure partnership with civil society and gain from its expertise.

4. The WHO regional meetings should be made more functional, effective, and properly timed, not merely as preparing ground for the COP but for monitoring progress, identifying areas for technical support, and for building capacity. It is evident that programs for capacity building are necessary not only for the nongovernmental organizations (NGOs) but also for the state parties, more particularly for officials of the Ministries of Health (MOH). If the WHO regional meetings are pre-designed after consultations with all stakeholders, it would be possible to combine the efforts of both Intergovernmental Organizations (IGOs), such as the World Bank, and the NGOs, and thereby make it possible to stretch the available resources, both financial and human, to the maximum. A case in point is a regional meeting/workshop organized in early March 2007 by the FCA on FCTC implementation, enforcement, and monitoring at the request of the Andine Regional Government organization that linked ministries of health from Chile, Bolivia, Peru, Ecuador, Colombia, and Venezuela. Representatives of Argentina, Uruguay, Brazil, and Paraguay were also invited. The meeting was highly valued because it helped the countries to go forward.

5. Priority should be given by the COP to have appropriate guidelines for the implementation of the provisions of the FCTC adopted as soon as possible, especially in the context of article 2.1 where the parties are encouraged to implement measures beyond those required by the FCTC. The guidelines should be providing best-practice standards or criteria for effective legislative, executive, administrative, or other measures necessary to be adopted by the parties.

6. In order to keep the momentum of the FCTC process, the interval between the COPs should be shortened as much as possible – at least until all the preliminaries, such as guidelines, protocols, and reporting arrangements for effective implementation of the FCTC are duly finalized. Regional meetings should also be taken into account in the planning process and a timeframe for all such meetings should be decided by the COP.

The FCA commends all members of the Conference of Parties for the meaningful steps taken in their respective countries to implement the provisions of the FCTC since the COP-1. Of course, it is always an onerous duty of each party to ask the question whether enough has been done to eliminate a human-made scourge that is afflicting millions of people each year. The urgency for action is because of this ongoing threat. The actions suggested here are made in that spirit for the earnest consideration of the COP-2.

Notes1. World Health Organization. Facts and figures about tobacco. Tobacco fact sheet for COP-1. Geneva, 5-16 February 2006.

Available at: http://www.who.int/tobacco/fctc/tobacco%20factsheet%20for%20COP4.pdf2. As of 31 March 2007, 52 countries that were parties to the convention have paid their voluntary assessed contributions,

while 61 were outstanding. Of the 34 countries that had become parties to the convention since the COP-1, only two parties have paid.

3. World Bank. Healthy development:The World Bank strategy for health, nutrition, and population results. Results, 24 April 2007. Available to download at: http://www.worldbank.org

4. Ibid. p. 225. “The numerical impact (of regulations) is hard to measure, but our gut feeling is that a full barrage of regulations could

knock 1% of the growth rate.” Spielman, A., Herzog, B., & Nobuyoshi, M. Emerging market tobacco trends. New York: Citigroup Global Markets, 10 October 2006; p. 65.

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The Framework Convention on Tobacco Control (FCTC) came into force on 27 February 2005 after the required minimum of 40 member states of the World Health Organization (WHO) had ratified the treaty. Parties to the FCTC then began implementing it by aligning national laws and regulations to the provisions and articles of the treaty, within the unique domestic contexts of individual countries. The success of this treaty therefore will lie in the implementation of national and regional regulations that are pro-public health. Only then can this treaty be seen to be fully successful. As parties continue to implement the FCTC, there is a great need to record the progress made while identifying the obstacles so that lessons can be shared and effective remedial action can be taken promptly, as appropriate. The FCA FCTC Monitor is one such tool.

Civil Society Monitoring of the Framework Convention on Tobacco Control: 2007 Status Report of the Framework Convention Alliance is a collation and analysis of the global situation on the domestication of the FCTC. This 2007 edition reports on 27 of the first 41 countries to ratify the treaty. The report has concentrated on some key provisions in the treaty, especially those that are FCTC priorities for reporting and those that the FCA has identified as priority areas. For example, chapter 2 highlights clear evidence that increasing tobacco taxes is effective in reducing tobacco use. Unfortunately, over half the countries sampled do not peg their tobacco taxation policies on the need to reduce use, but rather to increase tax collection only. In fact, most countries are still not adjusting the tobacco tax rate to account for inflation. This gap needs to be bridged so that taxation can realize the win-win situation of increased revenue and a reduction in tobacco use as envisaged in article 6 of the FCTC.

Chapter 3 analyzes the extent to which the public is protected from exposure to tobacco smoke. It is clear that many of the participating countries have not yet put legislative requirements in place to effectively protect members of the public from exposure to tobacco smoke. Indeed, most of those that have some level of protective legislation have not yet attained high levels of enforcement, and thus are only partially protecting the public from

the negative effects of tobacco smoke. Only 100 percent smoke-free environments effectively protect the public. Comprehensive legislation must be followed by high and effective levels of enforcement so that the public good benefits fully.

Chapter 4 discusses tobacco products’ package warning and labels. Most of the 27 countries now have legislation on package warnings that require approval by a national authority. However, there is still room for improvement when it comes to the inclusion of pictures on packages, rotations of the messages, inserts with health messages, and the size of the messages. This visual mode of communication with those who use tobacco products is an important cost effective means of reaching the public. The warnings and labels should cover an area beyond the minimum required by the FCTC, and use clear messages and colour pictures, that are rotated regularly, in order to communicate effectively.

Chapter 5 addresses progress in the regulation of tobacco advertising, promotion, and sponsorship. Most of the 27 countries surveyed report having legislation banning tobacco advertising, promotion, and sponsorship. However, the differences in the way these terms are defined introduces an element of difficulty in global comparisons. We therefore need to develop global standards and guidelines that will then be used to legislate the ban in advertising, promotion, and sponsorship.

Chapter 6 examines the rather neglected field of tobacco-dependence treatment. The data gathered shows that tobacco dependence treatment is generally a low priority for most countries. Systems have not yet been put in place to ensure that those dependent on tobacco products have access to treatment. Telephone quitlines are showing great promise in tackling this problem and should be explored during implementation in each country. There is also a need to develop and operationalize treatment guidelines while facilitating access to information and dependence medication.

Control of the illicit trade in tobacco products is covered in chapter 7 where it is identified as a rather difficult problem in most parts of the

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world. Smuggling is difficult to measure and the current estimates are at best just a proportion of the actual magnitude. Countries urgently need to conduct a reliable survey to estimate the scale of the problem, even as they put in place an effective tracking system in the supply chain.

Chapter 8 first analyzes issues in the regulation of tobacco products and the fact that very little is know about what the industry adds to tobacco products and what actually ends up being consumed in the open markets. Surely public health is more important and has more value than tobacco company trade secrets, especially if those secrets happen to be poisonous! More than half of the countries participating in the 2007 FCA FCTC Monitor lack requirements for testing and measuring the contents and emissions of tobacco products. Similarly, most do not require tobacco companies to disclose the contents or emissions of their products to governments. The discussion also shows that some countries are making good attempts at gaining some knowledge about the contents of the tobacco products in their markets.

Unfortunately, the data being analyzed is largely from the tobacco industry and therefore not fully upholding the core principle of tobacco control. Although this vacuum needs to be filled, we must keep in mind the fact that our meagre resources in tobacco control should first address those articles whose public health impact is clear and known, even as we plan to build capacity in tobacco products’ regulation. Guidelines need to be developed to enable countries to adopt and use standards and methods that contribute positively to the regulation of tobacco products.

Chapter 8 next deals with the need for education, communication, training, and public awareness. Most data collectors report that the public has access to information on the health risks of tobacco and is aware of the value in tobacco cessation. But information on the tobacco industry is, at best, limited by the industry’s resistance to disclosure and so cannot contribute to the much-needed pool of knowledge. On the issue of sales to and by minors, the vast majority of countries have legislation to address the issue. However, enforcement is low, with more than half the countries having low or no enforcement at all.

More than half these countries still allow the sale of single cigarette sticks rather than packs only. The data show that there are gaps in the provision of adequate information on the effects of tobacco use and especially information that touches on the tobacco industry. It is also clear that where legislation exists to address various angles of access by youth to tobacco products, enforcement is not optimal and therefore this vulnerable group is not protected. Comprehensive legislation therefore must be followed by effective enforcement.

Chapter 8 concludes by covering the need for research, surveillance, and exchange of information. It is clear from the data of the 2007 FCA FCTC Monitor that half the countries do not have a surveillance system in place. Even those that do have a system report that surveillance is irregular and depends on external funding without a regular budget. Another challenge is the lack of technical expertise that would develop the indicators to be used in the surveillance and cooperation across various disciplines. Engagement with international organizations for effective transfer of technical expertise, and support for tobacco control activities, is less than optimal. There is therefore a need to support countries in developing technical expertise and lobbying for dedicated national budgets that will address the need to generate the much-needed data from surveillance and further research.

Chapter 9 deals with tobacco control infrastructure and programming that will contribute to the reduction of tobacco consumption. This encompasses a well-thought-out strategy, an action plan, a dedicated budget, and responsible actors that include civil society and nongovernmental organizations. A focal point for tobacco control within governments is crucial for the success of implementation of tobacco control programs.

Chapter 10 takes us through the key processes that began with the International Negotiation Body (INB) meetings, which created the initial momentum to make the FCTC one of the most widely and rapidly supported treaties in the history of the United Nations. This chapter reminds us of the greater awareness about tobacco control that has been created globally since the FCTC came into force and especially

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after COP-1. With the awareness has come better legislation, improved funding for tobacco control activities, and, especially, opportunities for civil society’s participation in the FCTC process. This chapter also raises concerns regarding the FCTC process – obstacles that include the delay in full functionality of the permanent COP secretariat; the delay in payment by parties of assessed contributions, and the possibility that the initial momentum behind the FCTC may be waning gradually, superseded by other priorities. These concerns should form the basis for priority setting at COP-2. The possible urgent actions therefore include:

• Setting a definite timeline for the establishment of the permanent secretariat;

• Streamlining and strengthening the financial base for the successful implementation of the FCTC;

• Improving effective participation by civil society as equal partners to contribute to the success of the FCTC;

• Improving communication infrastructure in the regions to scale up the overall global response to FCTC implementation;

• Developing, approving, and implementing appropriate guidelines and protocols for different aspects of tobacco control; and

• Shortening the period between COPs until preliminaries, such as guidelines, protocols, and reporting arrangements, for effective implementation of the FCTC are duly finalized.

With this first report of the FCA FCTC Monitor, the process of FCTC implementation has truly taken off but it needs more resources to facilitate a stronger response, especially in low-

and middle-income countries. Because these are also the countries where the industry is moving to establish new markets, the need for implementation of the FCTC is urgent if we are to stem the growing numbers of young people addicted to tobacco products.

We plan to publish another edition of the FCA FCTC Monitor report in the days preceding each COP meeting. The next report will be a collation and analysis of what countries are doing to implement the FCTC and will provide updated information. As a reporting mechanism, it will rely heavily on accurate data collection in each country and the technical expertise of the FCA network. Successive FCA FCTC Monitor reports will chronicle experiences that will inform future interventions in public health, even beyond tobacco control.

As a way forward, this first edition of the FCA FCTC Monitor report should serve as a wake-up call to countries on the importance of a reliable system to collect and collate data on tobacco control. It also provides a blueprint for the development of tools and indicators to monitor the implementation of the FCTC by each country. These uniform tools and indicators will enable easy comparison of the progress in implementation, both regionally and globally.

Successive editions of the FCA FCTC Monitor will be a source of reliable, up-to-date, and internationally recognized information on the status of global tobacco control and should generate positive competition among countries in the protection of public health.

For this is just the beginning!

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Board of Directors

Mary Assunta, ChairPhD Candidate, University of SydneyAustralia/Malaysia

Deborah ArnottDirector, Action on Smoking & HealthUK

Eduardo BiancoPresident, Research Center of the Tobacco Epidemic Director, Tobacco Control Program InterAmerican Heart FoundationUruguay

Richard A. DaynardProfessor of Law, Northeastern UniversityChair, Tobacco Products Liability ProjectUSA

Ross HammondDirector, International Grants ProgramCampaign for Tobacco Free KidsUSA

Shoba JohnProgramme DirectorHealthBridgeIndia

Paula JohnsREDEH-CEMINA – Human Development NetworkBrazil

Ehsan LatifCoordinator, Coalition for Tobacco Control Society for Alternative Media and ResearchPakistan

Akinbode OluwafemiEnvironmental Rights Action Nigeria

Regional Coordinators

AfricaAhmed E.O. Ogwell – Kenya

AmericasLaura Salgado – Honduras

Eastern MediterraneanHani Algouhmani – Saudi Arabia

Southeast Asia and Western PacificE. Ulysses Dorotheo – Philippines

FRAMEWORK CONVENTION ALLIANCE (FCA)

DirectorLaurent Huber

Chief Operations OfficerElizabeth Furgurson

Program/Research AssistantsSandy GarçonAnnie Singkouson

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