A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

WHO Library Cataloguing-in-Publication Data

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC.

1.Smoking - prevention and control. 2.Tobacco use disorder –

prevention and control. 3.Tobacco use cessation. 4.Health policy.
I.World Health Organization.

ISBN 978 92 4 159663 3 (NLM classification: WM 290)

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2 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

A POLICY PACKAGE TO REVERSE
THE TOBACCO EPIDEMIC
Monitor tobacco use and
prevention policies
Protect people from
tobacco smoke
Offer help to quit tobacco use
Warn about the dangers
of tobacco
Enforce bans on tobacco
advertising, promotion
and sponsorship
Raise taxes on tobacco
Contents

7 INTRODUCTION
10 THE VISION FOR TOBACCO CONTROL
13 THE PACKAGE OF POLICIES AND
INTERVENTIONS
: Protect people from tobacco smoke
: Offer help to quit tobacco use
: Warn about the dangers of tobacco
: Enforce bans on advertising, promotion and sponsorship
: Raise taxes on tobacco products

31 SURVEILLANCE, MONITORING AND

EVALUATION
33 AND NATIONAL TOBACCO CONTROL
PROGRAMMES
35 CONCLUSION
36 DEFINITIONS
37 REFERENCES

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 5

 TOBACCO USE IS A RISK FACTOR FOR SIX OF THE
EIGHT LEADING CAUSES OF DEATH IN THE WORLD

8
Millions of deaths (2005)

1 Other
tobacco-
caused
diseases*
0

Ischaemic Cerebro
Cerebro- Lower Chronic HIV/AIDS Diarrhoeal TTuberculosis Trachea, T
Tobacco use
heart vascular respiratory obstructive diseases bronchus,
disease disease infections pulmonary lung cancers
disease

Hatched areas indicate proportions of deaths

that are related to tobacco use and are
coloured according to the column of the
respective cause of death.

*Includes mouth and oropharyngeal cancers,

oesophageal cancer, stomach cancer, liver
cancer, other cancers as well as cardiovascular
diseases other than ischaemic heart disease
and cerebrovascular disease.

Source: Mathers CD, Loncar D. Projections of

global mortality and burden of disease from
2002 to 2030. PLoS Medicine, 2006, 3(11):
e442. Additional information obtained from
personal communication with Mathers.

Source of revised HIV/AIDS figure: AIDS

epidemic update. Geneva, Joint United Nations
Programme on HIV/AIDS (UNAIDS) and World
Health Organization (WHO), 2007.

6 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

Introduction

Tobacco is the single greatest preventable cause of death in the world today,
killing up to half the people who use it. More than one billion people worldwide
currently smoke tobacco – about one quarter of adults – and tobacco use
currently kills more than five million people worldwide each year. Tobacco use
continues to grow in developing countries due to steady population growth along
with aggressive tobacco industry marketing efforts.
If current trends continue, tobacco will kill more than eight million per year by
2030. By the end of this century, tobacco may kill a billion people. It is estimated
that more than three quarters of these deaths will be in low- and middle-income
countries.1
Tobacco use is a risk factor for six of the eight leading causes of death in the
world. Smoking tobacco causes cancer of the lung, larynx, kidney, bladder,
stomach, colon, oral cavity and esophagus as well as leukaemia, chronic bronchitis,
chronic obstructive pulmonary disease, ischaemic heart disease, stroke, miscarriage
and premature birth, birth defects and infertility, among other diseases. This
results in preventable human suffering and the loss of many years of productive
life. Tobacco use also causes economic harm to families and countries due to lost
wages, reduced productivity and increased health-care costs.
Tobacco use is often – incorrectly – perceived to be solely a personal choice. This
is belied by the fact that when fully aware of the health impact, most tobacco
users want to quit but find it difficult to stop due to the addictiveness of nicotine.
Moreover, a powerful global industry spends tens of billions of dollars annually
on marketing and employs highly skilled lobbyists and advertisers to maintain and
increase tobacco use.2
Several strategies have been shown to reduce tobacco use. However, more than
50 years after the health dangers of smoking were scientifically proven, and
more than 20 years after evidence confirmed the hazards of second-hand smoke,
few countries have implemented effective and recognized strategies to control
the tobacco epidemic. Developing countries are even less likely to have done so;
women and young adults in these countries have been specifically targeted by the

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 7

 tobacco industry as having the greatest potential for increasing tobacco industry
sales and profits.3 Additionally, in some countries governments have a direct or
indirect interest in tobacco growing and manufacturing, which further impedes
action.
International efforts led by WHO resulted in rapid entry into force of the WHO
Framework Convention on Tobacco Control (WHO FCTC),4 which has 168
signatories and more than 150 Parties. The WHO FCTC provides the principles
and context for policy development, planning of interventions and mobilization
of political and financial resources for tobacco control. Achievement of tobacco
control goals will require coordination among many government agencies,
academic institutions, professional associations and civil society organizations at
the country level, as well as the coordinated support of international cooperation
and development agencies.

TOBACCO WILL KILL OVER 175 MILLION PEOPLE

WORLDWIDE BETWEEN NOW AND THE YEAR 2030
Cumulative tobacco-related deaths, 2005–2030
200
Cumulative tobacco-related deaths (millions)

W
World
180
Developing countries
160
Developed countries
140

120

100

80

60

40

20

2005 2010 2015 2020 2025 2030

Source: Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030.
PLoS Medicine, 2006, 3(11):e442.

8 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

Parties to the WHO FCTC have committed themselves to protecting the health
of their populations by joining the fight against the tobacco epidemic. To help
countries fulfil the promise of the WHO FCTC and turn this global consensus into
a global reality, this document presents – a policy package that builds
on the measures of the WHO FCTC that have been proven to reduce smoking
prevalence.5
The package is an integral part of the WHO Action Plan for the
Prevention and Control of Non-communicable Diseases that will be presented at
the 61st session of the World Health Assembly. This follows from the adoption of a
resolution at the 53rd session in 2000 giving priority to the prevention and control
of these diseases.
Tobacco control requires strong political commitment as well as the participation
of civil society.6 This document is meant to serve as a reference for stakeholders
at country level to help them translate the tobacco control policies of the
package into practice. It is meant to assist planning, building and
evaluating national and international partnerships, while facilitating access to
financial resources for tobacco control activities. It is presented in four sections:
O The vision for tobacco control
O The package of policies and interventions
O surveillance, monitoring and evaluation
O and national tobacco control programmes.

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 9

 The vision
for tobacco control
The package encourages policy-makers along with the rest of society,
including civil society, health-care providers and others, to envision a world free
of tobacco use. Furthermore, the package provides the tools to create
a world where tobacco use declines by promoting a legal and socio-economic
context that favours tobacco-free living. The goal is a world where no child or
adult is exposed to tobacco smoke.
The policy package to reduce global tobacco use requires that proven
tobacco policies and interventions be implemented, that they be informed by
data from systematic surveys designed to target and refine implementation, and
that rigorous monitoring is done to evaluate their impact. Interventions should be
implemented with a high level of coverage; partial implementation is generally
inadequate for reducing tobacco use in the population. To implement the
policy package, countries need to:
O onitor tobacco use
O rotect people from tobacco smoke
O ffer help to quit tobacco use
O arn about the dangers of tobacco
O nforce bans on tobacco advertising and promotion
O aise taxes on tobacco products.

10 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

 The table on the following page presents a summary of the policies and
interventions of . The policies are complementary and synergistic.
For example, increasing taxation will help tobacco users quit, reduce the number
of new tobacco users and protect people from second-hand smoke. Bans on
tobacco industry promotion and anti-tobacco advertising will educate people
about the health risks of tobacco use, alter public perceptions of smoking and
facilitate political decision-making. They will also support the enforcement of
tax legislation, ad bans and smoke-free laws. Rigorous monitoring is necessary
to obtain baseline information, target activities, track progress and evaluate the
results of interventions.

Raise children in smoke-free environments

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 11

 Policies and interventions of the package
PROTECT PEOPLE FROM TOBACCO SMOKE
Intervention 1 Enact and enforce completely smoke-free
environments in health-care and educational
facilities and in all indoor public places
including workplaces, restaurants and bars
OFFER HELP TO QUIT TOBACCO USE
Intervention O1 Strengthen health systems so they can
make tobacco cessation advice available as
part of primary health care. Support quit
lines and other community initiatives in
conjunction with easily accessible, low-
MONITOR cost pharmacological treatment where
appropriate
TOBACCO USE
WARN ABOUT THE DANGERS OF TOBACCO
Cross-
cutting Intervention 1 Require effective package warning labels
activity Intervention 2 Implement counter-tobacco advertising
1
Intervention 3 Obtain free media coverage of anti-tobacco
Obtain activities
nationally-
representative ENFORCE BANS ON TOBACCO ADVERTISING, PROMOTION
and AND SPONSORSHIP
population-
based periodic Intervention 1 Enact and enforce effective legislation
that comprehensively bans any form of
data on key
direct tobacco advertising, promotion and
indicators of
sponsorship
tobacco use
for youth and Intervention 2 Enact and enforce effective legislation to
adults ban indirect tobacco advertising, promotion
and sponsorship
R AISE TAXES ON TOBACCO PRODUCTS
Intervention 1 Increase tax rates for tobacco products and
ensure that they are adjusted periodically to
keep pace with inflation and rise faster than
consumer purchasing power
Intervention 2 Strengthen tax administration to reduce the
illicit trade in tobacco products

12 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

The package of
policies and interventions
The following are strategies that have been shown to reduce tobacco use. They
have been successful in many countries, and there are indications that they have a
synergistic impact.

Protect people from tobacco smoke

Objective: Completely smoke-free environments in
all indoor public spaces and workplaces, including
restaurants and bars
Second-hand smoke causes a wide range of diseases, including heart disease,
lung cancer and other respiratory ailments.7 There is no known safe level of
second-hand smoke exposure. Completely smoke-free environments are the only
proven way to protect people adequately from the harmful effects of second-hand
smoke. Smoke-free environments not only protect non-smokers,8 they also help
smokers who want to quit.9

Intervention 1. Enact and enforce completely smoke-free

environments in health-care and educational facilities as well as in
all indoor public places including workplaces, restaurants and bars
Because second-hand smoke causes illness, it is unacceptable to permit smoking
in any part of any health-care facility, from peripheral health posts or clinics to
major hospitals. All indoor health-care facilities should be smoke-free, including
facilities run by governments, nongovernmental organizations (NGOs) and private
health-care services.

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 13

 SMOKE-FREE AREAS ARE POPULAR
Support for comprehensive smoking bans in bars and
restaurants after implementation
100%

80%

60%

40%

20%

0%

New Zealand New York

Y City California Ireland Uruguay

New Zealand Ireland

Asthma and Respiratory Foundation of New Zealand. Aotearoa Office of Tobacco Control. Smoke-free workplaces in
New Zealand smokefree workplaces: a 12–month report. Ireland: a one-year review. Dublin, Department of Health
Wellington, Asthma and Respiratory Foundation of New Zealand, and Children, 2005 (http://www.otc.ie/uploads/1_Year_
2005 (http://www.no-smoke.org/pdf/NZ_TwelveMonthReport.pdf, Report_FA.pdf, accessed 5 November 2007).
accessed 5 December 2007).
Uruguay
New York City Organización Panamericana de la Salud (Pan-American
1. Chang C et al. The New York City Smoke-Free Air Act: Health Organization). Estudio de “Conocimiento y
second-hand smoke as a worker health and safety issue. actitudes hacia el decreto 288/005”. (Regulación de
American Journal of Industrial Medicine, 2004, 46(2):188–195. consumo de tabaco en lugares públicos y privados).
2. Bassett M. Tobacco control; the New York City experience. New October 2006 (http://www.presidencia.gub.uy/_web/
York City Department of Health and Mental Hygiene, 2007 (http:// noticias/2006/12/informeo_dec268_mori.pdf, accessed
hopkins-famri.org/PPT/Bassett.pdf, accessed 8 November 2007). 5 December 2007).

California
California bar patrons field research corporation polls, March
1998 and September 2002. Sacramento, Tobacco Control Section,
California Department of Health Services, November 2002.

14 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

In addition to health-care facilities, all educational facilities should be made
smoke-free. Making universities smoke-free is particularly important in order to
protect young adults from exposure to smoking as well as to second-hand smoke.
The WHO FCTC stresses the importance of making all indoor workplaces
smoke-free.10 The Parties to the WHO FCTC have unanimously adopted detailed
guidelines on protecting people from second-hand smoke.11 Smoke-free laws
protect workers and the public and do not harm businesses – other than the
tobacco industry.
In high-income countries, smoke-free public places and workplaces have been
shown to reduce tobacco consumption by 3–4%.9 Smokers who work in smoke-
free workplaces are more than twice as likely to quit smoking as those who work
where smoking is permitted.12
Governments can more easily prohibit smoking in facilities under their direct
control (e.g. government offices). However, because the vast majority of people
in most countries work in the private sector, it is important to make all indoor
workplaces smoke-free by law. Within any one sector (e.g. restaurants or bars), it
is desirable to make all entities smoke-free at one time rather than only those of a
given size or characteristic. Uniform implementation of smoke-free laws within a
sector ensures a level playing field among all affected businesses. Public transport
vehicles and stations, including taxis, should also be smoke-free.
The enactment of smoke-free policies in restaurants, bars, clubs and casinos
may be challenging. However, experience in a growing number of countries and
subnational areas shows that it is possible to enact and enforce effective bans
in these establishments and that doing so is popular with the public, does not
harm these businesses and improves health.13, 14, 15 Economic data can be used to
counter false tobacco industry claims that establishing smoke-free places causes
economic harm.16, 17
Legislation is required to implement smoke-free places, as voluntary policies
have proven ineffective. Ventilation and separate smoking rooms do not reduce
exposure to second-hand tobacco smoke to an acceptable or safe level.18, 19
Good planning, adequate resources, strong political commitment, effective use
of mass media, meticulous legal drafting and participation by civil society are
essential.20 When implementing legislation on smoke-free places, it is critical
that governments generate broad public support through public education
campaigns.21 Educational campaigns oriented to business owners about the

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 15

 benefits of smoke-free workplaces, including the fact that they do not harm
business, can reduce opposition from the business community.
Once enacted, laws establishing smoke-free places must be well enforced. It
may be necessary to enforce smoke-free policies and legislation more actively
in the period immediately after smoke-free laws are enacted in order to
demonstrate the government’s commitment to ensuring compliance. Once a high
level of compliance is achieved, it may be feasible to reduce the level of formal
enforcement, as maintenance of smoke-free places is largely self-enforcing in
areas where the public and business communities support smoke-free policies and
legislation.
Placing the responsibility for enforcing smoke-free places on the owners and
management of facilities is the most effective way to ensure compliance with
the laws. In many countries, business owners have a legal duty to provide
safe workplaces for their employees. Levying fines and other sanctions against
business owners is more likely to ensure compliance than fining individual
smokers. Enforcement of legislation and its impact should be monitored regularly.
Assessing and publicizing the lack of negative impact on business following
enactment of smoke-free legislation will further enhance compliance with and
acceptance of smoke-free laws.

Offer help to quit tobacco use

Objective: Easily accessible services to manage tobacco
dependence clinically at 100% of primary health-care
facilities and through community resources
Because most tobacco users are dependent on nicotine, an addictive drug, it is
difficult for them to quit even when they make a concerted effort to do so. Tobacco
users who understand their risk of tobacco-related disease and premature death
are more likely to try to quit. Once the decision to quit is made, most tobacco
users who quit do so without intervention, but assistance greatly increases quit
rates.22, 23 Of daily smokers who try to quit unaided, 90–95% will relapse.22

16 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

Managing tobacco dependence is primarily the responsibility of a country’s health-
care system, including government, social security, NGOs and private clinical
services.24 Because clinical management interventions focus on the actions of
individuals, they are less cost effective in reducing overall tobacco use than are
other strategies. Nonetheless, cessation interventions are important
to help individual tobacco users quit in order to protect their health and lives.
Additionally, clinical management interventions provide a greater impact on health
and are much more cost effective than most other health-care system activities.25
Governments implementing tobacco control interventions have a role to play
in helping tobacco users quit. Even with implementation of tobacco control
strategies that have been shown to increase quit rates – higher prices, banning all
advertising, marketing and promotion, restricting places where people can smoke
and educating smokers about the harms of tobacco – many tobacco users will
have difficulty quitting. Support for tobacco users who are trying to quit may also
reduce opposition to other policy elements of the package. Tobacco
cessation services can be subsidized by governments using revenues from tobacco
taxation.
There are two main interventions to facilitate tobacco user cessation. The first is
counseling, including face-to-face advice from physicians and other health-care
workers incorporated into regular medical care as well as over the telephone
via quit lines and community programmes. The other is access to low-cost
pharmacological therapy.

Intervention O1. Strengthen health systems to make tobacco

cessation advice available through primary health care, quit
lines and other community resources, in conjunction with easily
accessible, low-cost pharmacological treatment where appropriate
Identification of tobacco users and provision of brief advice should be integrated
into primary health-care services and other routine medical visits, and should include
ongoing advice reinforcing the need to quit. Brief cessation counseling is effective
and low cost. Cessation counseling is most effective when it includes clear, strong
and personalized advice to quit from health-care practitioners as part of general
medical care.22, 23 Physician advice can be especially powerful when it is related to
issues of specific interest to the patient (e.g. during pregnancy, consultation for heart
or lung symptoms). Warnings from health professionals, who are generally highly
respected, about the risks of tobacco use are usually well received. Quit rates also
increase when counseling is delivered by a variety of health workers.22

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 17

 Tobacco cessation advice is relatively inexpensive because it occurs within
already-existing health-care services that most people access at least
occasionally. However, it requires that health-care workers, particularly
physicians, be motivated to provide advice. Lay health workers, who are not
medical professionals but have been trained to provide basic health services,
could also be helpful with health education and cessation interventions. Health-
care workers can become involved in local and national tobacco control activities;
every health-care professional should be an advocate for policies and
interventions.
Cessation advice and counseling can also be provided in settings other than
health-care delivery, including via telephone quit lines that should be free
of charge, rely on live operators rather than pre-recorded messages and be

NICOTINE REPLACEMENT THERAPY (NRT)

CAN DOUBLE QUIT RATES

150%
Increased likelihood (%) of abstinence after six months, as compared to no NRT

100%

50%

0%

Gum Patches Nasal spray Inhaled Sublingual

nicotine nicotine

Source: Silagy C et al. Nicotine replacement therapy for smoking cessation.

Cochrane Database System Review 2004, (3):CD000146.

18 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

accessible to the public at convenient times. Quit lines are most effective in
countries where fixed or mobile telephone service is widespread and the public
is accustomed to making phone calls for services; quit lines require financing and
staff training to answer incoming calls and provide appropriate counseling or
referral for services. Quit lines should provide information similar to that available
from face-to-face counseling, such as outlining reasons to quit, preparation for
cessation and coping techniques.
Quit lines are most effective when staff make follow-up phone calls to people
to check on callers’ progress and provide encouragement to quit, maintain
abstinence or make another quit attempt in case of relapse. Multiple follow-up
calls at regular intervals have the greatest likelihood of keeping patients
committed to long-term cessation.26 In addition, community groups, non-health-
care service providers and community leaders can be important sources of both
motivation and information on quitting smoking.
Pharmacological treatment of nicotine addiction should ideally be used in
conjunction with advice and counseling, although it is also effective when
provided separately.22, 23 Cessation medications can double the likelihood
that someone will successfully quit, and this likelihood increases further if the
medication is administered in conjunction with counseling. Medications include
nicotine replacement therapy (NRT), which can be made available over-the-
counter in the form of trans-dermal patches, lozenges, chewing gum, sublingual
tablets, oral inhalers and nasal spray. There are also prescription medicines
such as bupropion and varenicline. NRT reduces withdrawal symptoms by
replacing part of the nicotine normally absorbed during smoking; bupropion is an
antidepressant that reduces craving and withdrawal symptoms; and varenicline
blocks the nicotine-induced pleasure perceived during smoking. NRT can usually
be discontinued one to three months after smoking cessation, although some
heavily addicted tobacco users may benefit from a longer course of treatment.
Most countries can use lower-cost counseling options effectively, even if
financial support for medication is beyond a country’s budgetary limits. However,
medication should be legally available for sale to patients even if they are not
subsidized by the government.

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 19

 Warn about the dangers of tobacco
Objective: High levels of awareness of the health risks
of tobacco use across age groups, sexes and places of
residence, so that all people understand that the result of
tobacco use is suffering, disfigurement and early death
Despite overwhelming evidence of the dangers of tobacco, relatively few tobacco
users worldwide fully understand the risks to their health.27 Most people know
generally that tobacco use is harmful but are unaware of the wide spectrum
of specific illnesses caused by tobacco, the likelihood of disability and death
from long-term tobacco use, the speed or degree of addiction to nicotine or the
harmfulness of second-hand smoke. Most people also grossly overestimate the
likelihood that they can quit when desired.
People are most likely to begin to use tobacco as adolescents or young adults.28
People in these age groups are typically less concerned about risks to their health
or lives and are more likely to engage in risky behaviours.29 They are also highly
susceptible to peer pressure and to advertising.30, 31 They may also be more likely
to become addicted to nicotine more quickly than people who are older, even if
they smoke only occasionally.32, 33
Public education through mass media about the health dangers of tobacco use –
smoking as well as second-hand smoke – can influence an individual’s decision
to start or continue to smoke. Important educational interventions include
disseminating information about the health risks of tobacco use to the general
public, targeting education to particular groups with higher rates of tobacco use
and/or lower levels of knowledge about tobacco use, and mandating warning
labels on cigarette packs and other tobacco products.
Ultimately, the objective of anti-tobacco education and counter-advertising is
to change social norms about tobacco use. By counteracting the glamorous
image of smoking portrayed by tobacco industry marketing and by reversing the
erroneous perception that tobacco use is a low-risk habit, societal pressures will
cause many individuals to choose not to use tobacco. Changing social norms in

20 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

 this way also increases support for other government initiatives to reduce tobacco
consumption.
Although anti-tobacco programmes directed at children are politically popular and
have broad public appeal, those conducted as part of health education classes
in schools have not demonstrated a large impact in reducing youth smoking
experimentation or initiation.34, 35 Considering the low return in prevention of
uptake, and the lack of long-term effects of these programmes, school programmes
should only be considered under a rigorous evaluation scheme and only when the
other policies and interventions are already in place. Focusing anti-
tobacco educational initiatives on children could weaken a more comprehensive
population-wide approach that might have greater long-term impact.36

SMOKERS APPROVE OF PICTORIAL WARNINGS

Impact of pictorial warnings on Brazilian smokers
80%

60%
73%
67%

54%
40%

20%

0%

Changed their opinion Want to quit as a result Approve of health warnings

about health consequences
of smoking

Source: Datafolha Instituto de Pesquisas. 76% são a favor que embalagens de cigarros tragam imagens que ilustram
males provocados pelo fumo; 67% dos fumantes que viram as imagens afirmam terem sentido vontade de parar de fumar.
Opinião pública, 2002 (http://datafolha.folha.uol.com.br/po/fumo_21042002.shtml, accessed 6 December 2007).

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 21

 Intervention 1. Require effective pack warning labels
Warning labels on tobacco packs are a cost-effective method of advertising
about the dangers of tobacco use, providing direct health messages to tobacco
users as well as to non-users who see the packs.37, 38, 39 This intervention can be
implemented at virtually no cost to the government.
The content and graphic presentation of pack warning labels should be
legislatively mandated to be visible and clear, and ideally should cover at least
half of principal pack display areas.40 Warning labels should also describe specific
health effects and diseases caused by tobacco use and should be periodically
rotated to continue to attract the attention of the public. Pictorial warnings are
effective for all smokers and are particularly important for persons who cannot
read or for young children whose parents smoke. In addition, labels should not
be permitted to include any wording or other indication that suggests that a
particular tobacco product is less harmful than other products because it is “low
tar”, “light”, “ultra-light” or “mild”. No cigarettes are safe, and the use of these
terms suggests incorrectly that some products are less harmful.41
As the health risks of smoking are well documented, legislation requiring warning
labels can usually be enacted with no objection from tobacco users. However, the
tobacco industry almost always resists these efforts, particularly if large, graphic
pictorial warnings are included. They do so because these efforts are known to be
effective.

Intervention 2. Implement counter-advertising

Government and civil society, including NGOs, should coordinate efforts to
educate the public and mobilize action against tobacco use.42 Information about
the health risks of tobacco use should be presented clearly, with the same quality
and persuasive power as tobacco industry advertising and marketing materials.
It is important to use the services of professional advertising agencies to
adapt or create and place materials that can compete for public attention with
intensive, pervasive and much better funded tobacco industry campaigns.
Counter-advertising campaigns can be costly. However, by adapting existing ads,
obtaining free or low-cost prime-time television and radio time if possible, and
increasing a country’s budget for tobacco control, it is possible to implement
sustained, effective, highly visible anti-tobacco messages that not only encourage
many tobacco users to quit, but also help change the context and increase the

22 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

likelihood of successful implementation of all other interventions.
Young teens exposed to effective television anti-tobacco messages are less
than half as likely to become established smokers,43 and adult smokers who
are exposed to anti-tobacco campaigns are more likely to quit smoking.44 The
tobacco industry has created its own anti-tobacco advertising, often in response
to government actions to curtail its business practices. However, these efforts are
ineffective in reducing smoking and may even increase smoking, especially among
the young.45

Intervention 3. Obtain free media coverage of anti-tobacco

activities
In addition to paid advertising, anti-tobacco educational campaigns can be
disseminated in the media through public relations efforts that promote television
and radio coverage, news stories in print, broadcast and online media as well
as letters to the editor and opinion articles. This process, sometimes referred to
as “earned media”, can be a highly effective46 and inexpensive way to educate
the public about the harms of tobacco, increase attention on tobacco control
initiatives and counter tobacco industry misinformation.
Well-designed media campaigns and implementation of policies
such as smoke-free places, counter-marketing and pack warnings can generate
substantial free media coverage. Press releases highlighting anti-tobacco policy
positions should be issued any time there is a development in tobacco control,
such as when laws are introduced or passed or new research findings are
released. The media will usually cover this type of news, so it is important to have
a strong tobacco control advocacy component contained within these stories.
Local stories with strong human interest angles backed by facts are likely to gain
the greatest attention from media outlets and their audiences. Media outreach
is often more successful when utilizing creative and unusual approaches that
bring a fresh perspective to the topic, so tobacco control advocates need to be
resourceful in developing new ways to gain media attention.

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 23

 Enforce bans on tobacco advertising,
promotion and sponsorship*

Objective: Complete absence of tobacco advertising,

promotion and sponsorship
The tobacco industry spends tens of billions of dollars worldwide each year on
advertising, promotion and sponsorship;2 a key component of tobacco control,
therefore, is a comprehensive ban on every form of marketing of tobacco products.47
Comprehensive advertising, promotion and sponsorship bans are highly effective
in reducing smoking among people of all income and educational levels.48 Partial
advertising bans have little or no effect on smoking prevalence.49 In high-income
countries, a complete ban that covers all media and all uses of brand names and
logos has been documented to decrease tobacco consumption by about 7%.49
Key target populations for tobacco advertising include the young, because
they are more vulnerable to becoming tobacco users and will likely be steady
customers for many years once they become addicted. Women, who in most
countries have traditionally not used tobacco, are viewed by the tobacco industry
as an enormous potential market because of their increasing financial and
social independence and have been targeted accordingly. Bans on advertising,
promotion and sponsorship should give special attention to marketing channels to
which these groups are exposed.
Enactment of legislation prohibiting tobacco industry advertising, promotion and
sponsorship may potentially face resistance because some businesses besides
tobacco manufacturers benefit from advertising expenditures. However, these
laws are easy to maintain and enforce if they are well written. Key features of
such legislation include:
O prohibitions on advertising in all types of media;
O restrictions on marketing activities by importers and retailers;
O restrictions on promotional activities involving the sporting and
entertainment industries.

24 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

 Voluntary restrictions on marketing and promotion are ineffective;50 government
intervention through well-drafted and well-enforced legislation is required
because the tobacco industry has substantial expertise in circumventing
advertising bans. The tobacco industry often touts advertising and promotion as
a means of market competition among brands for current tobacco users, thereby
disguising its primary purpose of attracting new users. Penalties for violations
of marketing bans must be high to be effective. Tobacco companies have large
amounts of money, and large punitive financial penalties are necessary to prevent
efforts to circumvent the law.

COMPREHENSIVE ADVERTISING BANS AMPLIFY

OTHER INTERVENTIONS
Average change in cigarette consumption 10 years after introduction
of advertising bans in two groups of countries
0% 14 countries with a comprehensive ba
ban 78 countries without a ban
Change in cigarette consumption

-1%
1%
-2%

-4%

-6%

-8%

-9%
9%
-10%

Source: Saffer H. Tobacco advertising and promotion. In: Jha P, Chaloupka FJ, eds. Tobacco control in developing countries.
Oxford, Oxford University Press, 2000.

* In Article 13 of the WHO Framework Convention on Tobacco Control, paragraph 1 states that: “Parties recognize that a
comprehensive ban on advertising, promotion and sponsorship would reduce the consumption of tobacco products.” At
the same time, Article 13 recognizes that the ability of some countries to undertake comprehensive bans may be limited
by their constitution or constitutional principles.

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 25

 Intervention 1. Enact and enforce effective legislation that
comprehensively bans all forms of direct tobacco marketing
To be effective, bans on direct advertising should be comprehensive and cover
all types of media and advertising. 51 Otherwise the tobacco industry will find
alternative advertising vehicles to carry their message to target populations.52, 53
If advertising is prohibited in a particular medium, the tobacco industry merely
shifts expenditures to places where advertising is permitted. Bans should include,
but not be limited to, newspapers and magazines, radio and television, billboards
and the Internet.
It is also important to ban point of sale advertising in retail stores, including
product displays and signage.54 This limits or blocks the ability of marketing
to cue tobacco users to make a purchase. This intervention can be further
strengthened by keeping cigarettes behind the counter and out of view so that
customers must ask specifically if the store sells them. This small extra effort
required of customers presents a large barrier to purchase.

Intervention 2. Enact and enforce effective legislation to ban

indirect tobacco advertising, promotion and sponsorship
Indirect tobacco advertising, promotion and sponsorship associates tobacco use
with desirable situations or environments and includes showing tobacco use in
films and television, sponsoring music and sporting events, using fashionable
non-tobacco products or popular celebrities to promote tobacco, and providing
messages that involve statements of identity (e.g. tobacco brands printed on
clothing). Indirect marketing improves the public image of tobacco and tobacco
companies.
Monitoring tobacco industry strategies is important for establishing effective
counter-measures. Ongoing monitoring can identify new types of marketing
and promotional activities that circumvent even the most clearly written
comprehensive bans. New media types and social trends will need to be
monitored, such as text messaging and underground nightclubs that are
advertised solely through word-of-mouth, in addition to monitoring traditional
media and marketing channels.

26 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

Raise taxes on tobacco products
Objective: Progressively less affordable tobacco
products
Raising the price of tobacco and tobacco products through tax increases is the
most effective way to reduce smoking. Higher cigarette prices reduce the number
of smokers and induce those who continue to smoke to consume fewer cigarettes
per day. Due to inelastic demand and the low share of total taxes in retail prices,
increasing tobacco taxes increases a country’s tax revenues, at least in the short-
and medium-term, even if reduced consumption is taken into consideration.55
Indeed, some countries have imposed tobacco taxation rates in excess of 75% of
the retail price.5
It is estimated that for each 10% increase in retail prices, consumption is reduced
by about 4% in high-income countries and by about 8% in low- and middle-
income countries. Smoking prevalence is reduced by about half those rates,56 with
variations associated with income, age and other demographic factors. Higher
tobacco taxes are particularly effective in preventing or reducing tobacco use
among teenagers and the poor.57, 58 Young people and low-income smokers are
two-to-three times more likely to quit or smoke less than other smokers after
price increases, because these groups are the most economically sensitive to
higher cigarette prices.53, 59

Intervention 1. Increase tax rates for tobacco products and

ensure that they are adjusted periodically to keep pace with
inflation and rise faster than consumer purchasing power
The goal of tobacco taxation is to make tobacco products progressively less
affordable. This means that governments must increase taxes periodically to
ensure that real price increases rise faster than consumer purchasing power and
that tax rates are increased for all tobacco products, including those that are the
most commonly smoked as well as the lowest cost products.

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 27

 If tax increases do not result in increases in real cigarette prices and do not rise
faster than purchasing power, then tobacco becomes relatively cheaper and more
affordable. As a result, consumption rises and the prevalence of tobacco use
increases. Furthermore, if taxes increase the prices of higher-end products but do
not significantly increase prices of cheaper ones, then the poor will be less likely
to reduce consumption since they are more likely to smoke cheaper products. In
addition, some tobacco users may shift to less-expensive brands or less-expensive
tobacco products, having the effect of keeping both individual expenditures
and nicotine levels constant and not reducing tobacco consumption.60 Different
tobacco taxation schemes may raise the same amount of revenue yet may either
greatly reduce or have little impact on tobacco use, depending on what products
are taxed, in what way and at what levels.

TOBACCO TAXES REDUCE CONSUMPTION

Relationship between cigarette consumption and excise tax rate in
South Africa
Consumption (left scale)

Excise tax rate (right scale)

E

2 500 45%

Excise tax rate (as a % of retail price)

Millions of packs

40%
4

2 000
35%
3

30%
3
1 500
25%
2

20%
2
1 000
15%
1

10%
1
500

5%
5

0 0%
0

1980
0 198
1985
855 1990
199
90
90 1995 2000
200
00 200
2005
0
05

Source: van Walbeek C. Tobacco excise taxation in South Africa: tools for advancing tobacco control in the XXIst century: success
stories and lessons learned. Geneva, World Health Organization, 2003 (http://www.who.int/tobacco/training/success_stories/en/best_
practices_south_africa_taxation.pdf, accessed 6 December 2007). Additional information obtained from personal communication with
van Walbeek.

28 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

To maximize the impact of taxation as a public health intervention, some
increased tax revenues resulting from increased tobacco taxation can be
earmarked to finance tobacco control and other public health and social
programmes. This makes tobacco tax increases even more popular with the
public, including tobacco users. In most countries, tobacco tax revenues are
hundreds or thousands of times higher than government spending on tobacco
control. Dedicating a larger share of these funds to tobacco control increases
the popularity of tobacco taxes and results in significantly increased funding
for implementation (e.g. counter-advertising campaigns, cessation
counseling, etc.).
Excise taxes can be applied according to the number (fixed-rate or specific taxes)
or value of items (ad valorem taxes), or a combination of both. Both types of
excises have their own strengths and weaknesses regarding retail prices and
tax revenues as well as product variety and quality. Specific taxes (e.g. one
dollar or the local equivalent per pack of 20 cigarettes) protect government
revenues from manufacturer price reductions, are easier to calculate and can
be automatically adjusted. They have a greater capacity to reduce tobacco
consumption, particularly if automatically adjusted for inflation. Specific taxes
should keep pace with inflation and should be periodically adjusted to account for
increased consumer purchasing power to maintain the same effect on reducing
tobacco consumption. Ad valorem taxes, on the other hand, keep pace with
inflation automatically and ensure higher revenues if the industry increases the
price of its products. However, in countries with large price differentials among
smoked tobacco products, increased ad valorem taxes may primarily provide an
incentive to smokers to switch to cheaper products, reducing the health benefits
of taxation.
Excise taxes applied at the manufacturer level and certified by a stamp on the
cigarette pack are the most practical method of levying taxes. This procedure
facilitates tax collection by reducing the administrative work required of
distributors and retailers, many of whom are smaller businesses that do not have
the capacity to account accurately for taxes received. For tobacco imports, excise
taxes are often applied at the port of entry as with any other custom duty. Sales
taxes or value added taxes (VAT) can also be collected at the port of entry or at
the retail sales level, as is the case with other products.

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 29

 Intervention 2. Strengthen tax administration to reduce the
illicit trade in tobacco products
A centralized taxation system focusing on manufacturers will also reduce illicit
trade by making it easier to monitor compliance. It may be necessary for countries
to strengthen the capacity of tax administration and the customs departments,
particularly where there are high levels of smuggling and/or tax evasion.
Inspection using state of the art technology, better communication among
customs officials and a high level enforcement are essential to reducing the
incentives of illicit trade. In addition, affixing tax stamps to every package
intended for retail sale, aggressive law enforcement supported by strong
legislation, effective government record keeping and mandatory use of
pack warnings in the local language are other effective means of reducing
the incentives of illicit trade. All these measures require strong government
commitment for curbing illicit trade activities.
Global action against tobacco smuggling is strengthening. Parties to the WHO
FCTC are negotiating and drafting a new, legally binding protocol on illicit trade
that will fight smuggling and counterfeiting as a part of global efforts to reverse
the tobacco epidemic. This protocol should markedly increase coordination at the
international level to address this important issue.

Support a tobacco-free world

30 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

 surveillance,
monitoring and evaluation

Objective: Effective surveillance, monitoring and

evaluation systems in place to monitor tobacco use

Cross-cutting activity 1: Obtain nationally-

representative and population-based periodic data on
key indicators of tobacco use for youth and adults
More than half of countries do not even have recent and nationally-representative
information on youth and adult prevalence of tobacco use.
Countries need accurate measures of tobacco use to plan tobacco control
strategies and interventions effectively in order to implement them where they
are needed, measure their impact and adjust them to ensure success. Accurate
data allow for appropriate intervention implementation, efficient impact
measurement and timely adjustment when necessary, which greatly improve the
likelihood of success. Any surveillance, monitoring and evaluation system must
use standardized and scientifically valid data collection and analysis practices.
Population surveys, using a representative, randomly selected sample of
sufficiently large size, can provide good estimates of tobacco use patterns within
an acceptable margin of error. Surveys can be conducted on tobacco use alone or
can be combined with surveys of other priority health issues.
Surveys should be repeated at regular intervals using the same questions,
sampling, data analysis and reporting techniques so that data are comparable
across different survey years. This is necessary to enable accurate evaluation of
the impact of tobacco control interventions over time.

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 31

 In addition to determining tobacco use status and consumption patterns in
order to calculate overall smoking prevalence within a country and among
subpopulations, other survey questions can be asked to discern knowledge,
attitudes and practices relating to tobacco use within the general population
and among specific groups as well as to determine public perceptions of tobacco
control measures.61
The Global Youth Tobacco Survey and Global Adult Tobacco Survey, as parts
of the Global Tobacco Surveillance System, can provide guidance on collecting
internationally comparable data by employing survey protocols with common
sampling procedures, a core questionnaire, field procedures and data management
across countries. Tobacco surveillance information is useful in designing,
monitoring and evaluating tobacco control interventions at the country level.
Other monitoring activities that should be undertaken include assessments of
government enforcement of and societal compliance with tobacco control policies,
including tax collection and tax evasion, smoke-free places as well as advertising
and marketing bans. Epidemiologic studies can be conducted to determine the
burden of tobacco-related illness and death and the impact of tobacco control
interventions on health. Polls should be conducted regarding public support for
tobacco control initiatives, including tax increases and establishing smoke-free
places, and should monitor perceived levels of compliance with policies.
Studies can also be conducted to determine the economic costs of smoking and
second-hand smoke from direct medical expenses as well as from productivity
losses. The extent and type of tobacco advertising, marketing and promotional
activities, including tobacco industry sponsorship of public and private events,
should also be monitored.

Help build a healthier future

32 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

 and national
tobacco control programmes
National action is critical in order to achieve the vision embodied in the WHO
FCTC. Building national capacity to carry out effective and sustainable national
tobacco control programmes is one of the most significant measures required to
combat the tobacco epidemic. A successful National Tobacco Control Programme
(NTCP) must, by definition, cover the entire population.
Strategic planning for the NTCP usually occurs centrally, within the Ministry of
Health. In larger countries, however, the programme must be designed for flexible
implementation by decentralizing authority to the regional/state/municipal and
county/village levels so that interventions can target and reach every citizen.62
Successful implementation of requires establishing a national
coordinating mechanism with an official government mandate for developing
and coordinating the implementation of a plan of action as well for building a
national infrastructure to carry out the implementation of the plan. Countries
with a central unit for planning and policy development in the Ministry of Health,
with local units for implementation and enforcement, are well placed to carry out
tobacco control activities.
Successful implementation of the policies also requires support from
senior levels throughout government as well as technical experts and persons
with expertise in planning and implementation. A well-staffed national tobacco
control programme, at both the central and local levels, can provide highly effective
leadership and coordinated work on legal issues, enforcement, marketing, taxation,
economics, advocacy, programme management and other key areas. Many countries
also need subnational tobacco control offices to ensure effective implementation of
the programme components as well to ensure that the tobacco control interventions
reach the target population. Dedicated staff greatly increases the ability to implement
successfully. Staff and resources must be identified to address:
O programme coordination, including support for subnational efforts;
O epidemiology and surveillance;
O economics and taxation;
O public education, media and pack warnings;

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 33

 O legal issues, including legislation and enforcement mechanisms in support
of comprehensive smoke-free environments and bans on advertising,
promotion and sponsorship.
An effective, well-staffed tobacco control programme can lead efforts to
implement effective interventions that can reduce the number of tobacco users
and save millions of lives. To prioritize programme capacity, countries may benefit
from hiring staff in an order consistent with the priorities based on potential
impact on tobacco use prevalence: increased taxation; marketing and promotion
bans; counter-advertising, including pack label warnings; protection from second-
hand smoke; and helping tobacco users quit. In smaller countries with limited
financial resources, one staff member may take on more than one role.
In addition to human resources, the NTCP needs material and financial resources.
No national programme can become operational and effectively implement the six
policies without logistic support and effective partnerships within the
government and between the government and interested parties outside of it.

Since the programme is carried out at the local level, success depends on ensuring
the availability of adequate resources and building the capacity of local public
health professionals and government leaders.
Countries receive ample funds in the form of tobacco taxes to support the cost of
additional staff and programmes. Data compiled from 70 countries, covering two
thirds of the world’s population, show that aggregate tobacco tax revenues in these
countries are more than 500 times higher than expenses for tobacco control activities.
Governments collect more than US$ 200 billion in tobacco tax revenues and have the
financial resources to expand and strengthen tobacco control programmes. Further
tobacco tax increases can provide additional funding for these initiatives.

A bright and healthy future

34 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

Conclusion
The number of people killed each year by tobacco will double over the next few
decades unless urgent action is taken. But just as the epidemic of tobacco-caused
disease is man-made, people – acting through their governments and civil society
– can reverse the epidemic. Although the tobacco epidemic can be countered,
this will depend upon countries taking effective steps to protect their populations.
Furthermore, the tobacco epidemic is making health inequalities worse, both
within countries, where in most cases the poor smoke far more than the wealthy,
and internationally, with poor countries soon to account for more than 80% of
the illnesses and death caused by tobacco.
The WHO FCTC, with over 150 Parties, demonstrates the global commitment
to taking action and identifies key effective tobacco control policies. Through
this landmark treaty, country leaders affirm their citizens’ right to the highest
attainable standard of health. To fulfil this fundamental human right, the
package of six effective tobacco control policies, if fully implemented
and enforced, will protect each country’s people from the illness and death
that the tobacco epidemic will otherwise inevitably bring. The impact of the
policies can turn the vision of the WHO FCTC into a global reality.
Tobacco is unique among today’s leading public health problems in that the
means to curb the epidemic are clear and within our reach. If countries have
the political commitment and technical and logistic support to implement the
policy package, they can save millions of lives. To implement the
package, countries need to undertake specific interventions to:
O Monitor tobacco use
O Protect people from tobacco smoke
O Offer help to quit tobacco use
O Warn about the dangers of tobacco
O Enforce bans on tobacco advertising and promotion
O Raise taxes on tobacco products.
This package will create an enabling environment to help current tobacco users
quit, protect people from second-hand smoke and prevent young people from
taking up the habit. As the tobacco epidemic is entirely man-made, the end of the
tobacco epidemic must also be man-made. We must act now.

MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC 35

 DEFINITIONS

Ad valorem tax Tax applied on the value of items (i.e. a percentage of the price)
Cessation Quitting smoking (no smoking for at least three months)
Current smoker Anyone who currently smokes any tobacco product on some or
all days
NRT Nicotine replacement therapy
Public place A place which the public, or a section of the public, is entitled
to use or which is open to, or is being used by, the public or a
section of the public (whether on payment of money, by virtue
of membership of a body, or otherwise)
Public place, All places accessible to the general public or places for collec-
indoor tive use, regardless of ownership or right to access that are
covered by a roof and one or more walls or sides, regardless of
the type of building material used or whether the structure is
permanent or temporary
Public transport Any vehicle used at any time by members of the public, includ-
ing taxis, usually for reward or commercial gain
Second-hand Both side stream smoke from the burning end of a cigarette or
smoke other tobacco product and mainstream smoke exhaled by the
smoker
Smoke-free air Air that is 100% smoke-free and in which smoke cannot be
seen, smelled, sensed or measured
Specific tax Tax applied on unit quantities of items (e.g. $1 per pack of 20
cigarettes)
Tobacco smoking Being in possession or control of a lit tobacco product
Tobacco Any form of commercial communication, recommendation
advertising and or action with the aim, effect or likely effect of promoting a
promotion tobacco product or tobacco use either directly or indirectly
Tobacco industry Tobacco manufacturers, wholesale distributors and importers of
tobacco products
Tobacco products Products made partly or entirely from tobacco leaf, which may
be smoked, sucked or chewed, or sniffed
Tobacco Any form of contribution to any event, activity or individual with
sponsorship the aim, effect or likely effect of promoting a tobacco product
or tobacco use either directly or indirectly
Workplace Any place used by people during their employment or work,
even if as an unpaid volunteer, including all attached or associ-
ated spaces as well as vehicles used in the course of work

36 MPOWER: A POLICY PACKAGE TO REVERSE THE TOBACCO EPIDEMIC

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