World Conference on Tobacco or Health: keeping the focus on the tobacco industry

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Anna Nicholson, Menzies School of Health Research

Follow Anna on Twitter @annaknicholson

The 16th World Conference on Tobacco or Health (WCTOH) was held in Abu Dhabi from March 17-21 2015, the first time it has been held in the Middle East. While this did not come without challenges (approximately 60 delegates, the majority from Bangladesh, were denied visas – see https://blogs.bmj.com/tc/2015/03/17/15th-world-conference-on-tobacco-or-health-regional-delegates-refused-visas/), the conference was attended by 2,184 delegates from over 100 countries. In the opening plenary, Dr Margaret Chan, Director General of the World Health Organization (WHO), rallied delegates to “keep the battle lines fresh and vigorous”, setting the tone for a program that focused on curtailing the tobacco industry. Despite many successes, delegates were sobered by the record profits recorded by a number of tobacco companies since the 15th WCTOH in 2012, notably in low income countries.

It is 10 years since the WHO FCTC came into force. So where are we now? Of the 178 countries with available data, about two thirds (125) show declining prevalence, but fewer than one in five (37) countries are on track to meet a 30% reduction by 2025. Country-specific surveillance shows 45 countries have comprehensive smoke free policies, 21 have adequate cessation support, 30 have graphic warning labels (>50% of pack), 24 have total advertising & promotion bans, and 32 have adequate taxation (75% of retail price). Day one of the scientific program focussed on growing evidence of the role of MPOWER, the technical package of technical measures and resources to achieve demand reduction provisions of the FCTC (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).

The conference theme was ‘Tobacco and Non-Communicable Diseases’ (NCDs). It was refreshing to be reminded of the importance to think beyond tobacco, and hear shared learnings from countering food, beverage and alcohol marketing. Delegates were urged to consider strategies that shift responsibility from the individual to industry and government, including product regulation, hard-hitting and sustained campaigns that raise public awareness, and advertising, promotion and sponsorship bans. Underpinning discussions was an awareness that funding available for preventing cardiovascular and other non-communicable diseases is in no way reflective of the scale of the NCD epidemic. Delegates heard about progress toward the World Health Assembly target to reduce tobacco use by 30% as part of the 25×25 global target of a 25% reduction in NCD deaths by 2025, and advocacy efforts to integrate the FCTC with the UN Sustainable Development Goals (SDGs).

The social, economic and environmental impacts of the tobacco industry were also acknowledged: issues such as food and water insecurity, air pollution, deforestation and pesticide use, as well as trade, farming and poverty. Delegates were urged to speak out against these tobacco-related inequalities. A number of symposia featured the heavy burden on low and middle income countries, with a particular focus on ‘best buy’ tobacco control strategies.

Attention was also drawn to many countries failing to provide adequate financial resources to tackle implementation of the FCTC (including high income countries), and the importance of keeping tobacco control efforts free of industry funding and influence. At a national level, delegates heard of the importance of strengthening primary health care systems, improving alliances, and advancing the role of these systems as agents for social change. The role and importance of civil society was also acknowledged, and delegates were encouraged to extend their partnerships and role as tobacco control advocates by including new champions for health reform.

Plain packaging was the focus of one plenary and a number of symposia. Nathan Smyth from the Australian Department of Health welcomed Ireland and the UK, which have both recently voted to introduce plain packaging, to “the greatest fight on Earth”. There was much discussion of lessons learned from current legal battles against the tobacco industry, which aims to slow the diffusion of plain packs by tying up resources, increasing the costs, and countering the evidence base. It was heartening to see the growing number of nations who have plain packaging in their sights despite these battles.

Lack of an evidence base was a key argument the tobacco industry used to fight Australia when it became the first country to introduce plain packs in 2012. Professor Melanie Wakefield used the analogy of a train leaving the station, collecting evidence from stops en route to the destination of reduced prevalence. Hot off the press of the April 2015 Tobacco Control supplement on plain packs, Professor Wakefield, Dr Michelle Scollo and other Australian researchers shared their ‘en route’ findings of the benefits of plain packs to reduce appeal and brand differentiation, focus attention on warning labels and reduce the ability to mislead consumers. Several presentations discussed the influence of pack shape and branding on consumer interpretations of attractiveness and harm, particularly for slim varieties, further highlighting the usefulness of standardised packaging. Delegates were also reminded of the synergistic effects of policies. Plain packs are not a magic bullet; rather they work together with complementary policies such as total bans on other forms of tobacco industry advertising and promotion. (For more about the supplement and the implications of the research findings, see https://blogs.bmj.com/tc/2015/03/18/blockbuster-special-issue-evaluation-of-the-australian-tobacco-plain-packaging-policy/).

Perhaps the most divisive debate was whether e-cigarettes should be viewed as a friend or foe of tobacco control. While the WHO urged caution, presenters in other symposia challenged the need for tight regulation, arguing this may stifle the emergence of potentially safer technologies. Experts appeared unanimous in their agreement that e-cigarettes produce metabolites known to cause disease such as lung cancer, emphysema, pulmonary fibrosis and cardiovascular events. However, the harm is greatly reduced compared to combustible cigarettes, and may be reduced further in new generations of e-cigarettes, particularly if new technologies can eliminate heating altogether. Delegates learned that some youth are using e-cigarettes before smoking cigarettes; however, no strong evidence of a “gateway effect” was reported. Nonetheless, delegates and presenters voiced concern over the appeal of flavours, the need to ban sales to minors, and the need to monitor effects of vaping in public. Given that e-cigarettes are an increasingly popular form of cessation assistance, the issue of how to best regulate them presents a pressing challenge. Professor Ken Warner reminded delegates to keep the focus on evidence-based tobacco control, look to more enlightened regulation (that does not discourage innovation) and continue to reduce the attractiveness of combustible cigarettes.

After four days of stimulating science, the conference ended with a rousing vision from the youth pre-conference delegation on their campaign “No More Tobacco in the 21st Century” (#NMT21C on Twitter), the prioritisation of which featured in one of the conference resolutions. Other conference resolutions centred on the FCTC: increasing signatories, achieving its recognition in the SDGs, and targets towards additional specific measures. There were also resolutions to treat tobacco uniquely in trade agreements, strengthen the Protocol to Eliminate Illicit Trade in Tobacco Products, and for a UN high level meeting to address the threat to humanity caused by the tobacco industry. Interestingly, despite the discussions and presentations throughout the conference, other broad action on NCDs was not featured in the conference resolutions.

The conference closed with the announcement that South Africa had won the bid for the 17th WCTOH, the first time the conference will be hosted by an African nation. The challenge was set with the words of Nelson Mandela: “I have walked that long road to freedom. I have tried not to falter; I have made missteps along the way. But I have discovered the secret that after climbing a great hill, one only finds that there are many more hills to climb”.

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