A powerful tool to reduce tobacco use in all countries
The MPOWER package
De Rüdiger Krech,
Kerstin Schotte et
Alison Commar
In 2008, WHO launched the MPOWER technical package to help countries implement the demand reduction provisions of the WHO Framework Convention on Tobacco Control. Data show that the MPOWER measures are an effective strategy that have helped reduce the number of tobacco users worldwide despite population growth. The results from the latest WHO trends report show that tobacco use prevalence has declined significantly in many countries, including low- and middle-income countries. Raising taxes on tobacco products would be an important measure to reduce tobacco use even further and raise national revenues needed to build resilient health care systems that have been weakened by the COVID-19 pandemic.
The WHO Framework Convention on Tobacco
Control (WHO FCTC) and its guidelines provide the foundation for countries to
implement and manage tobacco control (World Health Organization, 2003). To help
make this a reality, WHO introduced the MPOWER technical package in 2008 (World Health Organization, 2008). This package assists countries to implement
effective interventions to reduce the demand for tobacco, in line with the WHO
FCTC.
Despite the challenges of the COVID-19 pandemic, many countries have persisted in advancing tobacco control as a key health priority
Since publication of the first WHO report on the global tobacco epidemic in 2008 (World Health Organization, 2008), the steady progress made by countries on tobacco control has been demonstrated in biennial updates. Despite the exceptional challenges brought on by the COVID-19 pandemic in 2020, that progress continues. Latest results show that, as of 2020, more than 5.3 billion people are covered by at least one MPOWER measure adopted at the highest level. Of the 5.3 billion, 4.3 billion - or 80% - live in low-and middle-income countries (LMICs). This means almost two-thirds (65%) of the combined populations of all LMICs are covered in 2020 by at least one MPOWER measure adopted at best-practice level. The number of LMICs with measures at this highest level reached 93 in 2020, having increased 5-fold since 2007, when only 17 LMICs had at least one measure in place. This means only 41 LMICs have yet to implement a best-practice MPOWER measure (World Health Organization, 2021).
This means almost two-thirds (65%) of the combined populations of all LMICs are covered in 2020 by at least one MPOWER measure adopted at best-practice level.
In 2020, the status of adoption of specific
MPOWER measures in LMICs was similar to the global status for most measures. LMICs
have adopted three out of the seven MPOWER measures at almost the same level as
all countries. These measures are: national bans on smoking in public places, national
bans on tobacco advertising, promotion and sponsorship, and running impactful
anti-tobacco mass media campaigns. In terms of monitoring the tobacco epidemic,
24% of LMICs had a best-practice surveillance system, while the global
proportion was 40% of countries. Cessation support, the MPOWER measure least
adopted globally, is provided in 13% of all countries, but in only 7% of LMICs.
Over half of all countries have mandated large graphic pack warning on
cigarette packages, but only 44% of LMICs have done so. Levying high taxes to
impact affordability of tobacco products is also an under-adopted measure in
LMICs, with only 12% having done so (World Health Organization, 2021).
LMICs have adopted three out of the seven MPOWER measures at almost the same level as all countries. These measures are: national bans on smoking in public places, national bans on tobacco advertising, promotion and sponsorship, and running impactful anti-tobacco mass media campaigns.
The implementation of the evidence-based MPOWER measures has led to a decline in global tobacco use prevalence: In 2000, around a third (32.7%) of the global population (both sexes combined) aged 15 years and older were current users of some form of tobacco. By 2020, this rate has declined to under a quarter (22.3%) of the global population. Assuming that current efforts in tobacco control are maintained in all countries, the rate is projected to decline further to around a fifth (20.4%) of the global population by 2025 (World Health Organization, 2021 (2)).
Comparison of LMICs as a group against the global trend line shows the same trend, though starting and ending with marginally higher rates. Although the global trend is heavily influenced by the trend in LMICs, given that 85% of the world’s population live in LMICs, the trend in LMICs is clearly downward, having already reduced by a third since 2000 - 33.4% in 2000 down to 22.8% in 2020.
Due to steady population growth in LMICs since 2000, the prevalence rates were not decreasing fast enough to halt the rise number of tobacco users until 2015, when the number peaked at 1.097 billion tobacco users aged 15 years and over, both sexes combined. Since then, the decline in tobacco use prevalence has translated into a reduction of the total number of tobacco users in LMICs down to 1.090 billion in 2020.
The 2025 voluntary target set under the NCD Global Action Plan is for countries to achieve a 30% reduction in tobacco use prevalence using 2010 level as baseline (World Health Organization, 2013). On current trends, 60 countries are likely to achieve at least a 30% relative reduction in tobacco use by 2025, assuming they are able to continue implementing tobacco control measures at the current pace or faster. 43 of the 60 countries on track are LMICs. In the previous tobacco trends report, only 32 countries were on track to reach the target (World Health Organization, 2019).
Due to steady population growth in LMICs since 2000, the prevalence rates were not decreasing fast enough to halt the rise number of tobacco users until 2015, when the number peaked at 1.097 billion tobacco users aged 15 years and over, both sexes combined.
Seeing so many LMICs likely to achieve the targets of the NCD Global Action Plan is inspiring progress, and shows that income level of a country is no barrier to implementing MPOWER and achieving results comparable with HIC countries. Still, LMICs face challenges similar to other countries to achieve the commitments countries have made through the WHO FCTC, the SDGs and the NCD Global Action Plan to reduce tobacco use and counter the tobacco epidemic. Countries should remain vigilant and maintain focus on adopting evidence-based measures that are proven to reduce tobacco use, and avoid distractions caused by the proliferation of newer products.
All of the MPOWER measures are effective in reducing tobacco but the evidence is clear that increasing tobacco taxes is the most effective way to reduce tobacco use.
As the world continues to fight the COVID-19 pandemic, the call to
“build back better” by building resilient health systems needs to
include tobacco control. Reducing tobacco use is not only a global
health priority, but also an economic, sustainable development, and
human rights issue. The costs of smoking have been estimated to drain
around US$ 1.4 trillion dollars from the global economy every single
year (Goodchild et al., 2018). All of the MPOWER measures are effective
in reducing tobacco but the evidence is clear that increasing tobacco
taxes is the most effective way to reduce tobacco use: Increasing
tobacco taxes to make tobacco products less affordable will improve
public health and save lives by discouraging kids from starting to use
tobacco products and encouraging current tobacco users to quit. At the
same time, it will raise national revenues to help support health
systems and tobacco control measures such as anti-tobacco mass media
campaigns and support for tobacco users that want to quit.
Momentum
gained to date can be leveraged for the future by accelerating what
countries are already doing to implement the WHO FCTC and bring down
prevalence rates. Every day of delay that passes results in more lives
at risk of premature death and disability from tobacco.
We must
all recommit to strengthening implementation of the WHO FCTC, strive to
adopt MPOWER measures at the highest level of achievement, and ensure
that all the people of the world are protected from the harms of tobacco
and nicotine.
Authors affiliation: The authors are staff members of the World Health Organization.
The authors alone are responsible for the views expressed in this publication
and they do not necessarily represent the decisions or policies of the World
Health Organization.
References
Goodchild et al., 2018. Goodchild M, Nargis N, Tursan d'Espaignet E.
Global economic cost of smoking-attributable diseases. Tobacco Control
2018;27:58-64 (https://tobaccocontrol.bmj.com/content/27/1/58.info).
World Health Organization, 2008. WHO Report on the Global Tobacco Epidemic, 2008: the MPOWER package. Geneva: World Health Organization, 2008 (https://apps.who.int/iris/handle/10665/43818).
World Health Organization, 2013. Global action plan for the
prevention and control of noncommunicable diseases 2013-2020. Geneva,
World Health Organization, 2013 (https://apps.who.int/iris/handle/10665/94384).
World Health Organization, 2021. WHO report on the global tobacco epidemic 2021: addressing new and emerging products. Geneva, World Health Organization, 2021 (https://www.who.int/publications/i/item/9789240032095).
World Health Organization, 2021 (2). WHO global report on trends in prevalence of tobacco use 2000-2025, fourth edition. Geneva, World Health Organization, 2021 (https://www.who.int/publications/i/item/9789240039322).
Footnotes
World Health Organization, 2013. Global action plan for the
prevention and control of noncommunicable diseases 2013-2020. Geneva,
World Health Organization, 2013 (https://apps.who.int/iris/handle/10665/94384).
Dr Rüdiger Krech is the Director of the Department of Health Promotion at the World Health Organization (WHO) in Geneva since September 2019. He heads WHO's work on risk factors such as tobacco consumption and harmful use of alcohol; he is responsible for work on health-promoting settings and programmes for more physical activity. In addition to the normative work, his team supports member states in public health legislation and ways to impose additional taxes on unhealthy products. Prior to this, Dr Krech was the Director of Universal Health Coverage and played a key role in placing this issue on the global health agenda.
From 2009-2014, Dr Krech was the Director of Social Determinants of Health and Equity, and was responsible, among other things, for organizing the World Conference on this topic. Prior to joining WHO, Dr Krech worked at the German Agency for International Cooperation (GiZ), where he developed and implemented the Social Protection agenda for Germany's development cooperation, and at the WHO Regional Office for Europe in Copenhagen, where he was Head of Unit for Healthy Ageing.Dr Krech studied educational science and human medicine and was one of the first public health (MPH) graduates of a German university in 1991. He was awarded a doctorate in public health (DrPH) at the University of Bielefeld. Dr Krech is married and has three adult daughters.
Dr Kerstin Schotte, a native of Germany, is a Medical Officer in the WHO Headquarters Department for Health Promotion, providing global scientific and technical leadership in matters related to capacity building in tobacco control.
In her first professional life, she was a medical doctor in Psychiatry and joined WHO in 2004 after finishing her MPH at Harvard University.
Alison Commar is a Technical
Officer in the No Tobacco Unit in WHO Headquarters. She works on data and
analytics to advocate for tobacco control. She completed her MA in demography
at the Australian National University, and held posts in the Australian
Government before joining WHO in 2008.
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