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Path Forward

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Now in its 20th year, The Tobacco Atlas has covered the tobacco epidemic over the most important two decades of global tobacco control. We face a daunting moment: a global COVID-19 pandemic that has shown starkly the need for stronger public health systems, an ever more complex landscape of tobacco products, and a resurgent tobacco industry taking advantage of a fragmented media environment rife with disinformation.

Amidst these dynamics, this 7th Edition of The Tobacco Atlas has an unequivocal message: tobacco control works.

For the first time since the founding of the Atlas, we are marking a clear decrease in global smoking prevalence. The Atlas highlights that there are many effective tools available to fight the tobacco epidemic: raising taxes on tobacco products; comprehensive marketing bans; mass media campaigns; plain, standardized packaging with graphic pack warnings; smoke-free places; and banning flavors. There is incontrovertible evidence that these interventions are the main reasons why smoking prevalence is declining in many countries or why growth in smoking rates has slowed in others.

And yet, we face the stark reality that, with population growth, there are more tobacco users in the world than ever before— more than 1 billion people smoke— with millions dying each year and economic costs amounting to trillions, all of which begs the question: How can we rapidly accelerate progress?

We still face the enormous influence of the tobacco industry, working relentlessly to rebrand itself behind a bogus narrative of “transformation.” Our findings that in 68 countries smoking has increased among youth segments demonstrate the industry’s determination to target youth for smoking. It is true that the tobacco landscape is changing, but changes occur in response to successful regulations that reduce the affordability, accessibility, appeal and demand for tobacco products. Consumer behaviors and social norms are changing, and with tools that have been proven to work we could accelerate the end of cigarettes as a mass consumer product.

We believe tobacco control can go further. One step forward would be to innovate in directly regulating the industry, similar to how other harmful industries such as weapons manufactures are regulated.  Generally, banning unhealthy products has had a poor record of effectiveness but removing the industry from the regulatory process—or at least significantly minimizing its size, influence, and power— would go a long way toward driving down tobacco consumption.

Policy coherence across government sectors must become a cornerstone of future work. Our research shows that the greatest successes typically happen when tobacco control proponents successfully negotiate potential tensions with other sectors, usually economic ones. Internal disconnect can lead to government working at cross purposes, for instance a health ministry promoting tobacco control policies while an industry ministry counterpart seeks foreign investment in new cigarette factories. In 2022, the Canadian government was embarrassed by their decision to permit tobacco industry investment in a government supported COVID vaccine company. These types of issues demonstrate a fundamental failure to “mainstream” tobacco control across government initiatives and illuminate why these efforts must be made.

More investment is necessary to push healthy narratives to dominate and quicken changing social norms. A common factor among countries with rapidly declining smoking rates is a sustained commitment to robust anti-smoking campaigns, with triple benefits: motivating quit attempts, suppressing smoking initiation, and creating public support for policy changes. These efforts have remarkable return on investment, and digital media channels have unleashed creativity and innovation especially among younger audiences.

Youth from around the world press Formula 1 auto racing to stop tobacco sponsorship.

Tobacco control requires a long-term commitment, and often countries with the largest problems have the scarcest resources. One of the largest obstacles is insufficient capacity and/or resources to promote and sustain these efforts. Though groups in many countries have found outside support such as private foundations and overseas development assistance, the tobacco control community must make stronger self-financing of government efforts and civil society a core goal of tobacco control efforts. These proponents can pressure governments for tobacco control protections for the long run.

Beyond funding, the tobacco control community must take major steps to integrate with global sustainability efforts. First, it must make better connections with related sustainable development efforts including those to protect the environment, eradicate poverty, and promote equity. It must develop young proponents and leaders more purposefully and energetically. The struggle against tobacco is exhausting and there needs to be a concerted effort to attract new people and ideas.

The public health community must also come to a thoughtful and pragmatic reckoning with novel tobacco products. These products have divided the community and the clearest beneficiary has been the tobacco industry. The community must come together to find evidence-based solutions to refute misinformation and misrepresentation of facts that undersell or oversell the benefits and harms.

Finally, the path forward will not be easy and the public health community must exercise patience and commitment. Our progress over the last two decades has not been linear, and the next two decades promise the same. As novel tobacco products have clearly demonstrated, new developments can turn much of the public health world on its head. The public health community must maintain the resolve to continue the fight even in the face of new setbacks.

Young people in Ukraine were instrumental in supporting policymakers who successfully promoted the 2022 tobacco control legislation. Sign translations include: “For tobacco free generations”, “Why are cigarettes sold in attractive packaging?!” and “The lights of tobacco kiosks are attractive to kids”. Photo credit: Life Advocacy Center, Ukraine
Young people in Ukraine were instrumental in supporting policymakers who successfully promoted the 2022 tobacco control legislation. Sign translations include: “For tobacco free generations”, “Why are cigarettes sold in attractive packaging?!” and “The lights of tobacco kiosks are attractive to kids”. Photo credit: Life Advocacy Center, Ukraine
Dr. Luong Ngoc Khue, Director of Vietnam Tobacco Control Fund, working with young people including sports and music personalities to celebrate the 2019 World No Tobacco Day.

References

Deaths Map:

GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020, 396: 1223-49.

Additional reading

Though not referenced directly in this chapter, here is some additional thought-provoking related reading.

 

Daube M. Exposing the vectors. Tobacco Control 2022;31:383. https://tobaccocontrol.bmj.com/content/31/2/383.

Hoek J, Edwards R, Waa A. From social accessory to societal disapproval: smoking, social norms and tobacco endgames. Tobacco Control 2022;31:358-364. https://tobaccocontrol.bmj.com/content/31/2/358.

Malone RE, Proctor R. Prohibition no, abolition yes! Rethinking how we talk about ending the cigarette epidemic. Tobacco Control 2022;31: 376-381. https://tobaccocontrol.bmj.com/content/31/2/376.

Puljević C, Morphett K, Hefler M, et al. Closing the gaps in tobacco endgame evidence: a scoping review. Tobacco Control 2022; 31:365-375. https://tobaccocontrol.bmj.com/content/31/2/365.

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