Providing a framework for building and sustaining tobacco control in low- and middle-income countries through policy change
De Tih Ntiabang,
Andrew Black et
Jacqui Drope
Over 80% of the world’s tobacco users live in low- and middle-income countries (LMICs), where the burden of tobacco-related illness and death is heaviest, (WHO 2021). The significant harms of tobacco use on LMICs are usually understood primarily as a health issue, (WHO FCTC Secretariat, 2016) and this overlooks the extensive impact of tobacco that is “rooted in social inequalities” (Drope, Lencucha, Magati, and Small 2016, p. 4). The WHO’s Framework Convention on Tobacco Control (WHO FCTC) is an evidence-based “blueprint” for tobacco control policies. Its inclusion in the Sustainable Development Goals (SDGs) demonstrates its key role in the contribution to the advancement of the wider social, economic, and environmental development agenda, not just health and wellbeing.
Addressing the tobacco epidemic through development assistance
In 2016, the Secretariat of the WHO FCTC launched the FCTC 2030 project. Currently funded by the Governments of Australia, Norway and the United Kingdom, the project supports Parties to the WHO FCTC that are eligible to receive official development assistance to advance sustainable development through an accelerated implementation of the WHO FCTC.
The cornerstone of the FCTC 2030 project is the provision of intensive support to beneficiary governments to utilise a multisectoral approach for tobacco control policymaking and implementation. Thus, engaging both the health and non-health sectors to cooperate on WHO FCTC implementation is a critical part of their efforts to achieve the SDGs.
The significant harms of tobacco use on LMICs are usually understood primarily as a health issue, and this overlooks the extensive impact of tobacco that is “rooted in social inequalities”.
Other key areas of the project include strengthening tobacco taxation
policies to reduce the affordability of tobacco products, ending tobacco
advertising, promotion and sponsorship, introducing effective graphic
health warnings on tobacco packages, and banning smoking in indoor work
and public places.
Thirty LMIC governments spread across all WHO regions now receive a combination of technical and financial support to lead and accelerate the kind of sustained policy response that have proven successful in other parts of the world.
Box 1: Countries supported by the FCTC 2030 Project
Phase I: Cabo Verde, Cambodia, Chad, Colombia, Egypt, El Salvador, Georgia, Jordan, Madagascar, Myanmar, Nepal, Samoa, Sierra Leone, Sri Lanka, and Zambia.
Phase II: Armenia, Costa Rica, Eswatini, Fiji, Lao People’s Democratic Republic, Mozambique, Serbia, Suriname and Tunisia.
Phase III: Bhutan, Burkina
Faso, Ghana, Iran (Islamic Republic of), Mongolia, Montenegro, Panama,
United Republic of Tanzania, and Timor-Leste.
Strengthening multisectoral coordination for tobacco control:
Article 5.2(a) of the WHO FCTC obliges Parties to establish or reinforce and finance a national coordinating mechanism for tobacco control. Such mechanisms are required to be multisectoral in nature and this “entails taking coordinated and focused whole-of-government actions to ensure coherence in tobacco control policies” (WHO FCTC Secretariat 2020, p.12), as recommended by the Global strategy to accelerate tobacco control 2019-2025(WHO FCTC 2019).
Thirty LMIC governments spread across all WHO regions now receive a combination of technical and financial support to lead and accelerate the kind of sustained policy response that have proven successful in other parts of the world.
Since 2017, several countries that are part of the FCTC 2030 project have received support from the Secretariat of the WHO FCTC to establish and strengthen coordination platforms and preparing countries to better coordinate efforts to put in place priority interventions and address tobacco industry interference. To date, national multisectoral coordination mechanisms for tobacco control are functioning in various countries including Cambodia, whose Ministry of Health received the 2021 World No Tobacco Day Award in recognition of their important contributions to tobacco control by establishing an interdisciplinary coordination mechanism for tobacco control (WHO Western Pacific, 2021), amongst other important policy actions.
Building strong evidence for tobacco control in LMICs:
Research evidence on the benefits of implementation of the WHO FCTC’s policy measures continues to mount globally.However, it is often challenging for policy makers working on tobacco control in LMICs to extrapolate these findings to their own local contexts.The FCTC 2030 project has responded by supporting targeted county-level Investment Cases for Tobacco Control that provide policy makers and other stakeholders a powerful tool to inform their policymaking. These cases analyse the health and economic costs of tobacco use in each country and the economic benefits that would come from implementing the key measures of the WHO FCTC in each country.
Recipient governments value these investment cases. During the launch of the Cabo Verde investment case, the Minister of Health and Social Security, Arlindo do Rosário, commented: “this study shows the large economic impact of tobacco consumption and all the costs that involves if no action is taken. It is urgent to tackle it and promote free-smoke policies to fight non-communicable diseases in Cabo Verde. We have clear strategies to defeat tobacco and I call on all of you to join this cause” (WHO Cabo Verde, 2019).
...“this study shows the large economic impact of tobacco consumption and all the costs that involves if no action is taken. It is urgent to tackle it and promote free-smoke policies to fight non-communicable diseases in Cabo Verde. We have clear strategies to defeat tobacco and I call on all of you to join this cause”.
Arlindo do Rosário, Minister of Health and Social Security, Capo Verde
Improving South-South and international cooperation with and amongst LMICs:
The Secretariat of the WHO FCTC has delivered this project in partnership with WHO and the United Nations Program for Development, as well as other experts from academia and civil society.
Also, through the project, FCTC 2030 countries have been afforded the opportunity to interact and learn from one another and share more widely with other LMICs their experiences working on policy change and implementation. Georgia, for example, has received assistance from the WHO FCTC Knowledge Hub on taxation and illicit trade (based in the University of Cape Town) and provided peer support to neighbouring countries Armenia, Ukraine, and Kazakhstan. Colombia forged a partnership with Brazil to learn more on how to institutionalize its national coordinating mechanism. Cabo Verde has also benefited from Brazil’s experience in tobacco use cessation and prevention. Sierra Leone has drawn important lessons from the technical expertise of Kenya in combating illicit trade in tobacco products.
Also, through the project, FCTC 2030 countries have been afforded the opportunity to interact and learn from one another and share more widely with other LMICs their experiences working on policy change and implementation.
Reinforcing the technical capacity of beneficiary governments:
The FCTC 2030 project enables the Secretariat of the WHO FCTC to proactively build governments technical and leadership capacity in tobacco control so that they can lead and accelerate the sustained policy responses that have proven successful in all parts of the world.
FCTC 2030 countries have ready access to critical and timely support from specialised WHO FCTC knowledge hubs and experts from a wide range of disciplines who provide technical assistance on issues like tobacco taxation, illicit trade, drafting of legislation, plain packaging, and the development of codes of conduct to isolate policymaking from the influence of the tobacco industry. Over the course of its participation in FCTC 2030, Zambian politicians and civil servants have worked with experts on the economics of tobacco farming, alternative livelihoods, and tobacco taxation to explore and address some of the barriers to accelerating policy change in Zambia and involving new stakeholders like the Ministry of Agriculture. The government of Chad benefited from expert advice and guidance on tobacco taxation and was able to raise its taxes from 24% of the retail price in 2018 to 50% in 2019, bringing Chad closer to the WHO’'s recommended level of at least 75%. This progressive increase in tobacco taxes will eventually lead to a reduction in the affordability of tobacco products, decrease the prevalence of smoking and will provide more domestic revenue to the Government of Chad.
FCTC 2030 countries have ready access to critical and timely support from specialised WHO FCTC knowledge hubs and experts from a wide range of disciplines who provide technical assistance on issues like tobacco taxation, illicit trade, drafting of legislation, plain packaging, and the development of codes of conduct to isolate policymaking from the influence of the tobacco industry.
An ongoing effort:
Though many LMICs have yet to fully establish the infrastructure for effective tobacco control, the Secretariat of the WHO FCTC continues to collaborate with LMICs to foster the broader health policy landscape to ensure the sustainability of tobacco control. However, the effectiveness of these efforts would be amplified if countries mainstream tobacco control across all government sectors and secure the policy coherence needed for the achievement of the SDGs.
Disclaimer: The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the secretariat of the WHO Framework Convention on Tobacco Control and the Protocol to Eliminate Illicit Trade in Tobacco products, nor the Governing Bodies of those treaties.
References
Drope, J., Lencucha, R., Magati, P. and Small, R., 2016. Tobacco control
governance in sub-Saharan Africa: implementing article 5.2 (a) of the
World Health Organization framework convention on tobacco control. In UNDP and WHO FCTC Convention Secretariat: New York, NY. Available at https://www.who.int/fctc/FCTC-5.2A-NCM-Africa.pdf?ua=1 (see page 4)
Tih Ntiabang is a Project Officer at the Secretariat of the WHO Framework Convention on Tobacco Control (WHO FCTC), based at the World Health Organization Headquarters in Geneva. In this role, Tih provides policy advice and technical assistance to LMIC governments that are part of the FCTC 2030 project. Prior to this, he was the Regional Coordinator (Africa) for the Framework Convention Alliance (FCA) for Tobacco Control. Email
Andrew Black is the Team Lead for Development Assistance at the Secretariat of the WHO Framework Convention on Tobacco Control (WHO FCTC), based at the World Health Organization Headquarters in Geneva. As part of his responsibilities, Andrew leads the delivery of the FCTC 2030 project. Before joining the Secretariat, Andrew was a civil servant at the United Kingdom’s Department of Health where he had many roles, including Tobacco Programme Manager for almost a decade. Email
Jacqui Drope has worked for 20+ years with global partners in academia, government, and the non-profit sector to address the inequities caused by tobacco use. She is currently a specialist technical advisor to the Development Assistance team in the FCTC Convention Secretariat at the World Health Organization.
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